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HomeMy WebLinkAboutNCC221292_FRO Submitted_20220404FINANCIAL 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. Henry Fork River Park 1. Project Name 2. Location of land -disturbing activity: County Catawba City or Township Hickory Highway/Street Sweet Bay Ln Latitude N 35"42'08.04" Longitude 81 °22'43.3" 3. Approximate date land -disturbing activity will commence: September 2020 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreational Park 5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 7.76 6. Amount of fee enclosed: $ 520.00 . 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 Kelly Winkler E-mail Address kwinkler@hickorync.gov Telephone 828-323-7431 Cell # Fax # 828-323-1042 9. Landowner(s) of Record (attach accompanied page to list additional owners): City of Hickory 828-323-1042 Name Telephone Fax Number 76 North Center Street 76 North Center Street Current Mailing Address Current Street Address Hickory NC, 28601 Hickory NC, 28601 City State Zip City State Zip 10. Deed Book No. 77 Page No. 184 Provide a copy of the most current deed. Part B. 1. Company(les) 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 Hickory, NC kwinkler@hickorync.gov Name 76 North Center Street Current Mailing Address Hickory NC, 28601 City State Telephone 828-323-7431 E-mail Address 76 North Center Street Current Street Address Hickory NC, 28601 Zip City State Fax Number 828-323-1042 Erb 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 City Current Street Address State 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. �I Vwoo V_Y1 Type or print pamp Title or Awfhoritv Signature - Date .I M(,a Notary Public of the County of a_ State of North Carolina, hereby certify that i rIV-1-611 wooappeared 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 ! Wl� day of �� , 20 _ZO Notary �6� 0 ' My commission expires 2 22— o 0&zz f C���