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HomeMy WebLinkAboutNCC241691_FRO Submitted_20240606 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone number is unavailable, place N/A in the blank.) Part A. 1. Project Name P74400-Overlook at Harris Creek 2. Location of land-disturbing activity: County Wake City or Township Wake Forest Watkins Road 35°52'52.6"N 78°30'11.5"W Highway/Street Latitude(decimal degrees) 35.8813° LOngitUde(decimal degrees) -78.5032° 3. Approximate date land-disturbing activity will commence:June 17,2024 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Utility Linear 5. Total acreage disturbed oruncovere-d ((including off-site borrow and waste areas): 2.8 acres Express:$750 Regular:$300 6. Amount of fee enclosed Total:$ 1,050 . The Express Permitting application fee is a dual charge. The normal fee of$100.00 per acre(rounded up to the next acre) is assessed without a ceiling amount. In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes❑x Enclosed ❑x No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Robert Turnbull E-mail Address robert.t.turnbull@dominionenergy.com Phone: Office# Mobile# 919.819.1846 9. Landowner(s) of Record (attach accompanied page to list additional owners): NCDOT Division 5, District 1 Name Phone: Office# Mobile# 1575 Mail Service Center 1575 Mail Service Center Current Mailing Address Current Street Address Raleigh NC 27699 Raleigh NC 27699 City State Zip City State Zip NCDOT RN/ NSA 10. Deed Book No. Page No. Provide a copy of the most current deed. Part B. 1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list of all responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is an individual(s), the name(s)of the owner(s)maybe listed as the financially responsible party(ies). Public Service Company of North Carolina, Incorporated andrew.moore@dominionenergy.com Company Name E-mail Address P.O.Box 1398 800 Gaston Road, Building A Current Mailing Address Current Street Address Gastonia NC 28053 Gastonia NC 28056-9486 City State Zip City State Zip Phone: Office# 704.718.4114 Mobile# Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation control plan and to conduct the anticipated land disturbing activity. 2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State business registry, give name and street address of the Registered Agent: CT Corporation System(NCSOS ID#0519077) Attn:Sherry McGinnes(Project ID#00P74400) CT-StateCommunications@wolterskluwer.com Name of Registered Agent E-mail Address 160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200 Current Mailing Address Current Street Address Raleigh NC 27615 Raleigh NC 27615 City State Zip City State Zip Phone: Office#302.777.0204 Mobile# Sherry McGinnes Name of Individual to Contact(if Registered Agent is a company) (b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated North Carolina agent who is registered on the NC Secretary of State business registry: N/A N/A Name of Registered Agent E-mail Address N/A N/A Current Mailing Address Current Street Address N/A N/A City State Zip City State Zip Phone: Office# N/A Mobile# N/A N/A Name of Individual to Contact(if Registered Agent is a company) (c) If the Financially Responsible Party is engaging in business under an assumed name, give name under which the company is Doing Business As. If the Financially Responsible Party is an individual, General Partnership, or other company not registered and doing business under an assumed name, attach a copy of the Certificate of Assumed Name. N/A Company DBA Name (d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other consultant who can assist in providing any necessary information regarding the plan and its preparation: S&ME, Inc. Imorgan@smeinc.com Engineering firm or other consultant E-mail Address Liane.R.Morgan, P.E. 704.523.4726 704.989.0672 Individual contact person (type or print) Phone: Office# Mobile# The above information is true and correct to the best of my knowledge and belief and was provided by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s) or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with the authority to execute instruments for the Financially Responsible Party). I agree to provide corrected information should there be any change in the information provided herein. Andrew Moore, P.E. Director- Engineering&Construction Type or print name Title or Authority Ot1U 5/23/2O2 `- Signature Date I, Y1ktC& Lk. f\kvaracito , a Notary Public of the County of C-rQS State of North Carolina, hereby certify that Pmd.X u.) 1'OVYC appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him/her. Witness my hand and notarial seal, this 'Z day of kt Q,j , 20 24 fr ts`.4 CLL. CYNTHIA M. ALVARADO ( y NOTARY PUBLIC ` • Gaston County seal North Carolina My commission expires LO 2 O2s My Commission Expires i D 1 5 Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple owners. Attach copies of this page as needed to list all landowners. Landowner 2 of Record: Wilson,Ronald Kent&Rose G. Name Phone: Office# Mobile# 4201 Mitchell Mill Road Current Mailing Address Current Street Address Wake Forest NC 27587 City State Zip City State Zip Deed Book No.2639 Page No.246 Provide a copy of the most current deed. Landowner 3 of Record: Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 4 of Record: Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 5 of Record: Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed.