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NCC241993_FRO Submitted_20240702
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 NCG01 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 Lots 1 & 2 - Culbreth Subdivision-PB 148, PG 196 '!f this project involves Amencan 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 Cumberland City or Township Greys Creek Macedonia Church Rd 35.0002 -78.7525 Highway/Street Latitude(dedmmdegrees) Long itude(decmaldegrees) 3 Approximate date land-disturbing activity will commence ASAP 4 Purpose of development(residential, commercial, industrial, institutional etc ) Residential 5 Total acreage disturbed or uncovered (including off-site borrow and waste areas) 0.53 6 Amount of fee enclosed $ 1 00 . 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 S900) Checks should be addressed to NCDEQ. 7 Has an erosion and sediment control plan been filed? Yes❑ Enclosed x❑ No ❑ 8 Person to contact should erosion and sediment control issues arise during land-disturbing activity Name Ricky Nelson E-mail Address ndiamond0499@gmail_com Phone Office# 910-237-1391 Mobile# 910-237-1391 9 Landowner(s) of Record (attach accompanied page to list additional owners) Diamond Builders of Hope Mills Inc 910-237-1391 910-237-1391 Name Phone Office# Mobile# 1212 Shawnee Ct 1212 Shawnee Ct Current Mailing Address Current Street Address Hope Mills NC 28348 Hope Mills NC 28348 City State Zip City State Zip 11649 10 Deed Book No Page No 826 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 tho company is a solo propnolorship or if fhe londownor(s)is an mdividual(s), the namo(s)of the ownor(s)may bo hsfod as the financially rosponsiblo party(ios) Diamond Builders of Hope Mills In ndiamond0499©gmail.com Company Name E-mail Address 1212 Shawnee Ct 1212 Shawnee Ct Current Mailing Address Current Street Address Hope Mills NC 28348 Hope Mills NC 28348 City State Zip City State Zip Phone Office# 910-237-1391 Mobile# 910-237-1391 Note If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form the landowners 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 Norman R. Nelson III Name of Registered Agent E-mail Address 1212 Shawnee Ct 1212 Shawnee Ct Current Mailing Address Current Street Address Hope Mills NC 28348 Hope Mills NC 28348 City State Zip City State Zip Phone Office# 910-237-1391 Mobile# 910-237-1391 Ricky Nelson 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 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. Ricky Nelson President Type or a e Title or Authority 5/14/24 Si nature Date I. Kelly Ivory , a Notary Public of the County of Robeson State of North Carolina, hereby certify that Ricky Nelson 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 14t11 day of May , 20 24 ,,`,�,pluenlq�yi ,,`cootry�,LY I Vp�y.,�,,� Notary � I ; 6 My commission expires 6/21/27 • UB �144 ,1VU11UU11110