NCC220412_FRO Submitted_20220126

EXPRESS APP. FEE: $65 X 3 ACRES
= $195
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM EXPRESS SUPPLEMENT = $750
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 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 Cagneys Midway
2. Location of land -disturbing activity: County -� --- City or Township
Highway/Street Business Hwy 52 Latitude 35' 58' 22.44"N Longitude 80° 13' 26.4"W
3. Approximate date land -disturbing activity will commence: 01-01-2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.7 acres
6. Amount of fee enclosed: $ $945 . 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 Brent Sievers, PE E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9 Landowner(s) of Record (attach accompanied page to list additional owners):
George Llanaj 336408-6928
Name Telephone Fax Number
801 S. Main Street
Current Mailing Address
Kernersville, NC 27284
Current Street Address
City State Zip City
10. Deed Book No. 2097 Page No. 1881
State
Zip
Provide a copy of the most current deed.
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):
George Llanaj [e-mail]
Name
801 S. Main Street
Current Mailing Address
Kernersville, NC 27284
City State
Telephone [phone]
E-mail Address
Current Street Address
Zip City State Zip
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City
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
Telephone.
Fax Number
State Zip
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:
Fleming Engineering, Inc.
Engineering Firm or other consultant
Brent Sievers, PE
[e-mail]
E-mail Address
336-544-6432
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.
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I ��^ Lec e S a Notary Public of the County of 15 44-t-N
State of North Carolina, hereby certify that C� eo✓S¢ L 1 G'^ a appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
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