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HomeMy WebLinkAboutNCC241304_FRO Submitted_20240606 Check if this project is ARPA-funded ❑ FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Kernersville Recreation and Event Center *If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below under which you applied for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: County Forsyth City or Township Kernersville 1223 Union Cross Road 36.097200 -80.080770 Highway/Street Latitude(decimal degrees) Long itude(decimal degrees) 3. Approximate date land-disturbing activity will commence:June 1 , 2023 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Rec & Event Center 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10'66 acres 6. Amount of fee enclosed: $$1 ,100 . The application fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes E Enclosed ❑ No ❑x 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Brian Starkey E-mail Address bstarkey@withersravenel.com Phone: Office# 919-469-3340 Mobile# 919-247-3065 9. Landowner(s)of Record (attach accompanied page to list additional owners): Town of Kernersville (336) 996-3063 (336) 992-0804 Name Phone: Office# Mobile# PO Box 728 134 E Mountain St Current Mailing Address Current Street Address Kernersville NC 27285 Kernersville NC 27284 City State Zip City State Zip 10. Deed Book No. 002626 Page No. 01 330 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)may be listed as the financially responsible party(ies). Town of Kernersville cswisher@toknc.com Company Name E-mail Address PO Box 728 134 E Mountain St Current Mailing Address Current Street Address Kernersville NC 27285 Kernersville NC 27284 City State Zip City State Zip Phone: Office# (336) 996-3121 Mobile# (336) 992-0804 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: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# 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: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# 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. 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: WithersRavenel bstarkey@withersravenel.corn Engineering firm or other consultant E-mail Address Brian H Starkey 919-469-3340 919-247-3065 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. Curtis Swisher Town Manager Type or print name Title or Authority 2 3 Signature Date I, Kfikk R. t'bolc , a NotaryPublic of the Countyof ++ ��r'Jlrll� State of North Carolina, hereby certify that 1�1t 1S SWIS/1P.r 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 11 ' day of Aril , 20 d13 OFFICIAL SEAL KEITH R. HOOKER Notary Public-North Carolina Notary FORSYTH COUNTY My Corrvrtqassipt9 gxpirea My commission expires 4- 2- a025 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: 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 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. Continued from Item I in Part B of the Financial Responsibility/Ownership Form for multiple parties. Attach copies of this page as needed to list all financially responsible parties. Company 2 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 4 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile#