HomeMy WebLinkAboutNCC220999_FRO Submitted_20220310FINANCIAL RESPONSIBILITYIOWNERSHIP 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. C-5604OF Blue Ridge Road Bike/Ped Improvements Project
1. Project Name g
2. Location of land -disturbing activity: County Wake City or Township Raleigh
Highway/Street Blue Ridge Road Latitude35.8002 Longitude-78.7075
3. Approximate date land -disturbing activity will commence: June 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Pedestrian
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 4.8 AC
6. Amount of fee enclosed: $ 325 . 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 Brian Roth-Roffy, PE
E-mail Address brian.roth-roffy@raleighnc.gov
Telephone 314-596-7360 Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT
Name
Telephone Fax Number
Current Mailing Address
Current Street Address
City State Zip
City State Zip
10. Deed Book No. Page No.
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.
City of Raleigh
richard.kelly@raleighnc.gov
Name
E-mail Address
PO Box 590
222 W Hargett St
Current Mailing Address
Current Street Address
Raleigh, NC 27602
Raleigh, NC 27601
City State Zip
City State Zip
Telephone 919-996-5575
Fax Number NIA
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:
Marchell Adams -David - City Manager Marchell.David@raleighnc.goy
Name of Registered Agent E-mail Address
PO Box 590 222 W Hargett St
Current Mailing Address Current Street Address
Raleigh, NC 27602. Raleigh, NC 27601
City State Zip City State Zip
Telephone 919-996-5575
Fax Number NIA
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.
Richard L. Kelly, P.E.
Type or print me
Signature
Engineering Services Director
Title or Auth rity
Date
I, U da Cane 1" I'VCfa Notary Public of the County off
State of North Carolina, hereby certify that Y r[ �,, +�' appeared
personally before me this day and being duly sworn acknowledged that th above form was
executed by him.
Witness my �,aael' notarial seal, this day of vat YL 2p
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