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HomeMy WebLinkAboutNCC216632_FRO Submitted_20211130FINANCIAL 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 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 Environment and Natural Resources. (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: Kamdon Ranch — EC Plan for Lots 8 and 54 - 56 2. Location of land -disturbing activity: County: Johnston City or Township: Hectors Creek Highway/Street: Pioneer St Latitude: 35.5241 Longitude: - 78.4075 3. Approximate date land -disturbing activity will commence: August 2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.9 acres 6. Amount of fee enclosed: 130.00 The application fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. (Example: a 9-acre application fee is $585). 7. Has an erosion and sediment control plan been filed? Yes No Enclosed: X 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name: Scott Lee E-mail Address: laura(),scottleehomes.com Telephone: (919) 553-2085 Cell: (919) 369-1937 Fax: (919) 9. Landowner(s) of Record (attach accompanied page to list additional owners): Scott Lee Homes, Inc. (919) 553 2085 Name Telephone Fax 104 State Avenue, Suite 103 104 State Avenue, Suite 103 Current Mailing Address Current Street Address Clayton NC 27520 Clayton NC 27520 City State Zip City State Zip 10. Deed Book No.: 5909 Page No.: 1 — 3 Provide a copy of the most current deed. 5886 388 - 390 5971 732 - 733 Part B. 1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all responsible parties on an attached sheet): Scott Lee Homes, Inc. Name 104 State Avenue. Suite 103 Current Mailing Address Clayton NC 27520 City State Zip Telephone: (919) 553-2085 scott(a-)scottleehomes.com E-mail Address 104 State Avenue, Suite 103 Current Street Address Clayton NC 27520 City State Zip Fax (919 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 Current Mailing Address City Telephone E-mail Address Current Street Address State Zip City Fax Number State Zip (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. - Laura S. Lee Name of Registered Agent 104 State Avenue, Suite 103 Current Mailing Address laura .scottleehomes.com E-mail Address 104 State Avenue, Suite 103 Current Street Address Clayton NC 27520 Cla City State Zip City Telephone (919) 553 2085 Fax Number (919) NC 27520 State Zip 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. P. Scott Lee L e or r nt-name L:::�= S'gnatur President, Scott Lee Homes, Inc. Title or Authority Date I, I ti �Gri _ a Notary Public of the County of State of North Carolina, hereby certify that R 'r�cj H- appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this day of 2021 AT K11Vq Notary Seal v' a = My commission expires