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HomeMy WebLinkAboutNCC241592_FRO Submitted_20240528 Financial Responsibility Ownership i ENGINEERING (Sedimentation Pollution Control Act) '' SERVICES One Exchange Plaza,Suite 304 Raleigh,NC 27601 This section to be completed by City of Raleigh staff Submittal Date Effective Date Transaction Number Permit Number LD- The remaining sections to be completed by the Applicant SECTION 1: GENERAL INFORMATION & INSTRUCTIONS This form is required to be completed, notarized and submitted with all Land Disturbing Permit applications. The information provided herein becomes an enforceable part of the approved Erosion and Sediment Control Plan and the Land Disturbing Permit listed above. Non-compliance may result in the assessment of civil penalties and could potentially affect all permits, inspections and/or Certificates of Occupancy for this Project. Should any of the information on this form change, a revised, executed form shall be submitted within thirty (30) days, said submission shall include a copy of any documents recorded with the Register of Deeds. The effective date of this form shall be the effective date as designated above by the City of Raleigh. No rights and liabilities associated with any designation shall incur until the effective date, or the effective date of transfer to any subsequent Party. Upon any delegation of an Applicant/Permittee or Financially Responsible Party, the Owner shall continue to receive notice at the address provided. A permit may not be transferred to a residential Home Owner's Association as the Applicant/Permittee or Financially Responsible Party, until the issued Land Disturbing Permit for this project is administratively closed by the Stormwater Management Division. Raleigh City Code §14-1011 sets forth that it shall be unlawful and a violation of this code for any person to give false information or misrepresentations in any application or permit required by this code. Failure to provide full disclosure of the requested information may be grounds for denial or revocation of a Land Disturbing Permit. Please complete all sections below. Type or print and, if information on the form is not applicable, place N/A in the blank. All pages of this form must be completed and submitted or the form will be rejected and returned. The property owner must initial each page of the form prior to submittal. SECTION 2: PROJECT INFORMATION PROJECT NAME North Ridge Country Club Cart Barn/Fitness Center PERMITTED PHASE(S) One Phase PROJECT ADDRESS 6612 Falls of Neuse Rd. NUMBER(S)WAKE COUNTY PARCEL ID 1717-33-7989 ANTICIPATED DATE OF January 31, 2024 PROJECT INITIATION EXPECTED DURATION OF PROJECT 9.12 Months ACREAGE OF LAND TO BE 1.7 acres DISTURBED PROPERTY OWNER'S INITIAL Stormwater Inspections Form 112 08.01.16 Page 1 of 5 SECTION 3: PROPERTY OWNER INFORMATION North Ridge Country Club, Inc. PROPERTY OWNER OF RECORD 6612 Falls of Neuse Rd. 919-846-9667 MAILING ADDRESS (NO P.O. BOX) TELEPHONE NUMBER FAX NUMBER Raleigh, NC 27615-6815 Jeff Earley (JEarley@northridgecc.org) CITY, STATE, ZIP E-MAIL ADDRESS The undersigned acknowledges that he is the Owner, or holds the Owner's power of attorney, of the property which is the subject of this application, and further states that the permitted land-disturbing activities are authorized to be conducted on the subject property with the full knowledge, permission and consent of the Owner. The undersigned acknowledges that he is the Property Owner for permit implementation, compliance and enforcement resulting under this Land Disturbing Permit and Unified Development Ordinance, Article 9.4. The Owner of the property upon which the land-disturbing activity is to be undertaken states and affirms that he has read and understands the statements and disclosures made in this form and that the information disclosed herein is true and correct to the best of his knowledge and belief. This form must be signed by the Owner of the property or by a person with authority to execute instruments, if the Owner is not an individual. This,the / day of Vct c , 20 73'. /rJ/ l 42 P Y OWNER S ATURE TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his hand and seal,this day of �i,n , 20 c 3 . km\e_ Marie_ fit740v'e5Cto r' Notary Public(print name) Notary Public Signature My Commission Expires: "a 3 r�CCOUn' i-i ttRa I Lt $fi Notary Public Title I P4ition ANNE MARIE ANTONESCU NOTARY PUBLIC Wake County Carolina My CommnExpires July 1,2023 PROPERTY OWNER'S INITIALS: Storm water Inspections Form 112 08.23.16 Page 2 of 5 SECTION 4: OWNER'S APPOINTED AGENT INFORMATION The Owner of the property upon which land-disturbing activities will be undertaken is required to either reside in or appoint an agent for service with business and residence addresses within Wake County, North Carolina. Section 4 must be completed if the Property Owner listed in Section 3 does not reside in Wake County, North Carolina and is optional for all others. The Owner of the subject property hereby appoints the following person as an agent to receive service of any notice, process, or pleading in any action or legal proceeding arising out of any matter relating to Unified Development Ordinance, Article 9.4. The Owner agrees that any notice, process, or pleading may be served by and through the undersigned appointed agent and such service shall have the same force and effect as if service was accomplished upon the Owner. Cr-7C Ze /g/71? NAME / TITLE 11,0%7% / 1 C.- Zeo%ZAI/ le (?/9) 8W-W7 COMPANY, IF APPLICABLE TELEPHONE NUMBER a/2i /XAolAite £� STREET ADDRESS (NO P.O. BOX) FAX NUMBER .jectrio7 °//,/7f/14,4Ce•Dr7 CITY, STATE, ZIP E-MAIL ADDRESS The undersigned' acknowledges that he/she is the Owner's appointed agent. This, the / day of Jsl2P , 20 ,23. - thil/e//' . AP AGENT NATURE TITLE IN WITNESS WHEREOF, the undersigned Notary Public has hereunto set his/her hand and seal,this - "day of Jan e , 20 013 . Ann 6, Marie Pvtto n eSc J / e Notary Public (print name) Notary Public Signature My Commission Expires: 7— /—oZ3 7CC oorr+t h� 'vta.I y S Notary Public Title/ ition t ANNE MARIE ANTONESCU NOTARY PUBLIC Wake County North Carolina My Commission iRiAl July 1,2023 PROPERTY OWNER'S INITIALS:0.----...- Stormwater Inspections Form 112 08.23.16 Page 3 of 5 SECTION 5: FINANCIALLY RESPONSIBLE PARTY INFORMATION The Owner of the subject property authorizes the following person or firm as the Financially Responsible Party for this Land Disturbing Permit. The Financial Responsible Party shall receive service of any notice, process, civil assessment or pleading in any action or legal proceeding arising out of any matter relating to the Land Disturbing Permit issued under this permit application and Unified Development Ordinance, Article 9.4. 1 e i 6' - e/&8 FINANCIALLY RESPONSIBLE PARTY TITLE %'///`i 4f eZe... "IX i 2o-c If!i/ $'/‘• ? 7 COMPANY, IF APPLICABLE TELEPHONE NUMBER a/Z , %,,c I fe ,O STREET ADDRESS (NO P.O. BOX) FAX NUMBER £ ii ,# 2V‘/� //fir e.y� .�/�Pee. ,9.7 CITY, S1'ATt, ZIP E-MAIL ADDRESS The undersigned acknowledges that he is the Financially Responsible Party for permit implementation, compliance and enforcement resulting under this Land Disturbing Permit and Unified Development Ordinance, Article 9.4. He has read and understands the statements and disclosures made in this form, that the information disclosed herein is true and correct to the best of his knowledge and belief. This form must be signed by the person or firm financially responsible for the land developing activity or other person with authority to execute instruments for the financially responsible party, if not an individual. This, the / day of 9wn.c- , 20 73 . FIN Y RESPO IBLE PARTY SIGNATURE TITLE IN WITNESS WHEREOF,�/ the undersigned Notary Public has hereunto set his hand and seal, this gilt" day of c t)viQi , 20 a.3 . Anne- Mar;e An-I—o,ne s c v , .e Notary Public(print name) Notary Public Signature �I My Commission Expires: 7'(- 93 ACC 0vn'h-O / `/�$4C �J' k Notary Public Title/Pos' ' n ` ANNE MARIE ANTONESCU NOTARY PUBLIC Wake County North Carolina My Commission Expires July 1,2023 (SEA PROPERTY OWNER'S INITIALS: e7 Stormwater Inspections Form 112 08.23.16 Page 4 of 5 SECTION 6: APPLICANT I PERMITTEE The Owner of the subject property authorizes the following person or firm as the Applicant/Permittee to receive service of any notice, process, civil assessment or pleading in any action or legal proceeding arising out of any matter relating to the Land Disturbing Permit issued under this permit application and Raleigh Unified Development Ordinance, Article 9.4. The Applicant/Permittee designated below is the person responsible for implementation of permit conditions and violation under Article 9.4 of the Raleigh Unified Development Ordinance. The Applicant/Permittee may be the landowner or another party who acknowledges that he is the Contractor responsible for completion of the project as approved. C/e /ler r.///- 40/M APPLICANT/PERMITTEE TITLE /1 7 elleo 4,4- /1s2 C (11 p16- �G‘2 COMPANY, IF APPLICABLE TELEPHONE NUMBER ,,6/2- 1;7 o71 emu« /t/ STREET ADDRESS (NO P.O. BOX) FAX NUMBER % /li�''li �� 2 7G/5— fo,�./ e�o�f�.�/jeer..93 CITY, STATE, ZIP FAIL ADDRESS The undersigned acknowledges that he is the Applicant/Permittee for permit implementation, compliance and enforcement resulting under the Land Disturbing Permit listed above and Unified Development Ordinance, Article 9.4. He has read and understands the statements and disclosures made in this form and that the information disclosed herein is true and correct to the best of his knowledge and belief. This form must be signed by the person or firm responsible for the permit or by a person with authority to execute instruments for the Applicant/Permittee, if not an individual. This, the / - day of VAG, , 207,. f,7/('/., A ER IT EE GNATURE TITLE IN WITNESS WHEREOF,the undersigned Notary Public has hereunto set his hand and seal,this / day of c , 20 a-�J J✓1� 1tnr e ( Ao rr e- ,✓l'('o vies c v Notary Public(print name) Notary Public Signature My Commission Expires: r/� 3 7fCGO +t'i A—nakysfi Notary Public Title/P tion ` ANNE MARIE ANTONESCU NOTARY PUBLIC Wake County North Carolina My Com0n)Expires July 1,2023 PROPERTY OWNER'S INITIALS:0:12Stormwater Inspections Form 112 08.23.16 Page 5 of 5