NCC242269_FRO Submitted_20240725

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 and/or
fax information unavailable, place N/A in the blank.)
Part A.1 . Project Name p Cha el Pines Subdivision
2. Location of land-disturbing activity: County Davidson City or Township Boone
Latitude 35.76917 Longitude 80.36417
Highway/Street SR 1156
3. Approximate date land-disturbing activity will commence: January 15,2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 9
6. Amount of fee enclosed: $ The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE:
Both fees are rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Justin R. Nifong [e-mail]
Telephone 704 562 5012 Ce11 # 704 562 5012 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Chapel Pines Development LLC 704 562 5012 919 882 8195
Name Telephone Fax Number
3409 Union Grove Rd 3409 Union Grove Rd
..._________
Current Mailing Address Current Street Address
Winston Salem, NC 27127 Winston Salem, NC 27127
City State Zip City State Zip
10. Deed Book No. 2656 Page No. 6 15 Provide a copy of the most current deed.
Part B.
1 . Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Chapel Pines Development LLC [e-mail]
Name E-mail Address
3409 Union Grove Rd 3409 Union Grove Rd
Current Mailing Address Current Street Address
Winston Salem, NC 27127 Winston Salem, NC 27127
City State Zip City State Zip
Telephone 704 562 5012 Fax Number 919 882 8195

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, 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
Telephone Fax Number
(c) In 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:
Engineering Firm or other consultant E-mail Address
Individual contact person(type or print) Telephone Fax Number
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 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 Person). I agree to provide corrected information should there be
any change in the information provided herein.
Justin R. Nifong Managing Member
or print me Title or Authority
yk
a ure Date (S-11°V7
AI --Ph %S , a Public of the of C4 YI, �r�►Y' l Notary County �,
.
State of North Carolina, hereby certify that 5IAsT-1 lA P., NI Poit0appeared personally
before me this day and being duly sworn acknowledged that the above form waxecuted by him.
Witness my hand and notarial seal, this S day of 20
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