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HomeMy WebLinkAboutNCC242058_FRO Submitted_20240715 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 7,8,9,10.11,12 , 24 and 26 The Farms Cumberland Fayetteville 2. Location of land-disturbing activity: County City or Township Albument St 35.008097 -78 792068 Highway/Street Latitude(dec,maI degrees) Longitude)decimal degrees) 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): 5.43 6. Amount of fee enclosed $1 .750 . 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 S250 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 S2,900). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed 1 No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Michael Poole michael.williamrhomes@gmail.com Name E-mail Address Phone: Office# 704-541-5772 Mobile# 704-430-4591 9. Landowner(s) of Record (attach accompanied page to list additional owners): William R Homes LLC 704541-5772 704-877-1178 Name Phone: Office# Mobile# 8000 Corporate Center Dr Suite 100 8000 Corporate Center Dr Suite 100 Current Mailing Address Current Street Address Charlotte, NC 28226 Charlotte, NC 28226 City State Zip City State Zip 10. Deed Book No. 10080 Page No. 0367 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). William R Homes LLC michael.williamrhomes@gmail.com Company Name E-mail Address 8000 Corporate Center Dr Suite 100 8000 Corporate Center Dr Suite 100 Current Mailing Address Current Street Address Charlotte, NC 28226 Charlotte, NC 28226 City State Zip City State Zip 704-541-5772 704-430-4591 Phone: Office# 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: Sids Mill Properties LLC jimmyray33@gmail.com Name of Registered Agent E-mail Address 8000 Corporate Center Dr Suite 100 8000 Corporate Center Dr Suite 100 Current Mailing Address Current Street Address Charlotte NC. 28226 Charlotte NC 28226 City State Zip City State Zip Phone: Office# 704-541-5772 Mobile# 704-877-1178 Jimmy Ray 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 William R Homes LLC jimmyray33©gmail.com Engineering firm or other consultant E-mail Address Jimmy Ray 704-541-5772 704-877-1178 Individual contact person (type or pnnt) Phone: Office tt Mobile tr 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. Jimmy Ray Owner Type or print name Title or Authority Signature Date 1 411. ((11 ( Cf I. , /< a I f a Nota Public of the County of State of North Carolina. hereby certify that l r► I i n k a t appeared personally before me this day and being duly sworn acknowledged$at the9ove form was executed by him/her. Witness my hand and notarial seal, this ( day of j(i 1 C , 20 1 R'+jc%c,,, t)(y(iv1 iT)H-47 U= My commission expires ��/ L `) C,QJ