HomeMy WebLinkAboutNCC221784_FRO Submitted_20220511FINANCIAL 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Collins Ridge -- Lot 2
2. Location of land -disturbing activity: County Chatham City or Township Chapel HIII
161 Ridge To 35.8510-76.2160
Highway/Street g p LatltUde(decimal degrees) LOngltude(decimal degrees)
I Approximate date land -disturbing activity will commence: 5/16/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): '94
6. Amount of fee enclosed: $ 100 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
B. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Lee Kane E-mail Address lee a@trinitydesignbuild.com
Phone: Office # 9193218344 Mobile # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Virginia & Kyle Miller N/A 9193218344
Name
3522 Oak Park Dr
Current Mailing Address
Saline, MI 48176
City State
10. Deed Book No. 2085
Phone: Office # Mobile #
3522 Oak Park Dr
Current Street Address
Saline, MI 48176
Zip City State Zip
Page No. 0558 Provide a copy of the most current deed.
Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Trinity Design Build
Company Name
213 N Gregson St
Current Mailing Address
Durham, NC 27701
City State ZIP
Phone: Office # 9193218344
lee@trinitydesignbuild.com
E-mail Address
213 N Gregson St
Current Street Address
Durham, NC 27701
City State Zip
Mobile # N/A
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Lee Kane
Name of Registered Agent
213 N Gregson St
Current Mailing Address
Durham, NC 27701
City
lee@trinitydesignbuild.com
E-mail Address
213 N Gregson St
Current Street Address
Durham, NC 27701
State Zip City
Phone: Office # 9193218344 Mobile # N/A
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
N/A
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
N/A
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record
N/A
Name
Current Mailing Address
City State
Deed Book No.
Landowner 4 of Record:
N/A
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
N/A
Name Phone: Office # Mobile #
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
MW
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
N/A
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
N/A
Company 5 Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
State
Zip
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA ame
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
th
Type or print name Title or Authority
Signature Date
I, , a Notary Public of the County of OtA,-\nae--,
State of North Carolina, hereby certify that (--e-c- ka n e. appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of a,,, , 20 'Z Z
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