HomeMy WebLinkAboutNCC216381_FRO Submitted_20211203FINANCIAL 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 Multi -Tenant Bldg on D Street
2. Location of land -disturbing activity: County Wilkes City or Township North Wilkesboro
Highway/Street 1103 D Street Latitude 36.1591 Longitude-81.1511
3. Approximate date land -disturbing activity will commence: 08/16/21
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.41
6. Amount of fee enclosed: $ 130 + 500 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Robert Melvin E-mail Address robert@petersdevelopmentllc.com
Telephone 704-252-4215 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Peters Development, LLC
Name
Telephone Fax Number
645 N. Main Street
645 N. Main Street
Current Mailing Address
Current Street Address
High Point NC
27260 High Point NC 27260
City State
Zip City State Zip
10. Deed Book No. 1286
Page No. 381 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.
Peters Development, LLC
robert@petersdevelopmentllc.com
Name
E-mail Address
645 N. Main Street
645 N. Main Street
Current Mailing Address
Current Street Address
High Point NC
27260 High Point NC 27260
City State
Zip City State Zip
Telephone 704-252-4215
Fax Number
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 State Zip
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
Telephone
State Zip City
Fax Number
State Zip
(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:
Blue Ridge Engineering, PLLC neil@ridge.blue
Engineering Firm or other consultant E-mail Address
C. Neil Shepherd, PE 336-838-2500
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.
Type or print nam '
�!3�_-
Signature
Title or Authority
L31Io 1 zl
Date
( cz ` �as a Notary Public of the County of Q
State of North Carolina, hereby certify that 'rL%S E -�I-T-2.5 C-'M-C- 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 r ' day of 20 �L-
'olkas
SoterouiaTsl otary
NOTAFNERUBLIC
Forsyth County, NC My commission expires
My Commission Expires October 11, 2022
PETERS DEVELOPMENT, LLC
2026
REFERENCE NO.
DESCRIPTION
INVOICE DATE
INVOICE AMOUNT
DISCOUNT TAKEN
AMOUNT PAID
Per Fee
8/16/21
130.00
130.00
CHECK DATE
CHECK NO.
PAYEE
DISCOUNTS TAKEN
CHECK AMOUNT
8/16/21
2026
NC DE Q
$130.00
2026 H
PINNACLE BANK EFRAUD p„oR a
PETERS DEVELOPMENT, LLC HIGH POINT, NC 27260
507 LINDSAY STREET 67-863/640 N
HIGH POINT, NC 27262 it
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Memo: Aug 16, 2021 130.00
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PETERS DEVELOPMENT, LLC
2027
REFERENCE NO.
DESCRIPTION
INVOICE DATE
INVOICE AMOUNT
DISCOUNT TAKEN
AMOUNT PAID
Expr Perm
8/16/21
500.00
500.00
CHECK DATE
CHECK NO.
PAYEE
DISCOUNTS TAKEN
CHECK AMOUNT
8/16/21
2027
NCDEQ
$500.00
PAY
TO THE
ORDER
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2027 Ia
PINNACLE BANK [O,R,,o4M4W
PETERS DEVELOPMENT, LLC HIGH POINT, NC 27260
507 LINDSAY STREET 87-863/640 x
HIGH POINT, NC 27262 k
Memo:
Five Hundred and 00/100 Dollars
NCDEQ
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DATE
Aug 16, 2021
AUTHORIZED SIGNATURE
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