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HomeMy WebLinkAboutNCC221125_FRO Submitted_20220413FINANCIAL 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. CMH Baker Drive Subdivision 1. Project Name Burke City orTownshi Valdese 2. Location of land -disturbing activity: County Y Township Valdese 4265 Baker Wive Latitude 35.75118406643615 Longitude-81.58651152931819 3. Approximate date land -disturbing activity will commence: 1 1 /1 /21 4. Purpose of development (residential, commercial, industrial, institutional, etc.):Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.7 Acres 6. Amount of fee enclosed: $1 %J . 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 EnclosedX 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Larry Carter E-mail Address Larry.Carter@Claytonhomes.com Telephone 865-518-0051 ext.5660 Cell # Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Michael And Timothy Baker Name Telephone Fax Number 2627 BYRD RD Current Mailing Address Current Street Address MORGANTON NC 28655 City State Zip City State Zip 10. Deed Book No.001 531 Page No.00480 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. CMH Homes, Inc. Larry.Carter@OakwoodHomes.com N E-mail Address ame 5000 Clayton Road Current Mailing Address Maryville, TN 37804 City State Zip Telephone865-518-0051 ext.5660 Current Street Address City Fax Number State M 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: CT Corporation System Name E-mail Address 160 Mine Lake Ct Ste 200 Current Mailing Address Current Street Address Raleigh, NC 27615-6417 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: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip Telephone City State Zip 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. mA � t' ks Type Title or Authority (OZ� 21 Date Y►.k a Notary Public of the County of I-ey\VVs s-Qe- II State of hereby certify that l a V c& ( appeared personally before me this day and being duly sw rn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this Z� day of 'r�� � 20 2 `����� •M'..Hq,Q,,, Notary TE : S• ' ea pF < SS r = My commission expires TENNE �"" Z _ NOTARY U61-IC