Loading...
HomeMy WebLinkAboutNCC220218_FRO Submitted_20220112FINANCIAL 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 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. Noland Farm Subdivision 1. Project Name 2. Location of land -disturbing activity: County Davidson City or Township Lexington Highway/Street Tussey Road Latitude 35d 49'4"N Longitude 80d 18'30"W 3. Approximate date land -disturbing activity will commence: 1/1/2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.70 6. Amount of fee enclosed: $ 0 . The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00). 7. Has an erosion and sediment control plan been filed? Yes Yes No Enclosed 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Jim Merrill E-mail Address jmerrill@sagamorehomes.com Telephone Cell # 704-902-1252 Fax # nla 9. Landowner(s) of Record (attach accompanied page to list additional owners): Bailey's Ridge, LLC Name Telephone Fax Number 1340 Creekshire Way, Ste 210 1340 Creekshire Way, Ste 210 Current Mailing Address Current Street Address Winston Salem, NC 27103 Winston Salem, NC 27103 City State Zip City State Zip 10. Deed Book No. DE 2477 Page No. 489-492 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. Sagamore Homes NC, Inc. jmerrill@sagamorehomes.com Name E-mail Address 1348 Westgate Center Drive, Suite 100 1348 Westgate Center Drive, Suite 100 Current Mailing Address Current Street Address Winston Salem, NC 27103 Winston Salem, NC 27103 City State Zip City State Zip Telephone 704-902-1252 Fax Number n/a 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 State E-mail Address Current Street Address Zip City Telephone 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: Name of Registered Agent Current Mailing Address City E-mail Address Current Street Address State Zip City Telephone Fax Number 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. Jim Merrill V? c c�- Type or print name Title or Authority re Date a Notary Public of the County of 'bald ! (, _ State of North Carolina, hereby certify that M 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 I I day of lI, 20�__ Seal Notary Public ti Davie County' my Comm. Exp. _ 10-03-2023 Q C A F,rr I`�50�\\�.. V I &� �6 [ ` Notary My commission expires a3