HomeMy WebLinkAboutNCC222182_FRO Submitted_20220613FINANCIAL 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 Birchwood Grove Subdivision Phase 3 and 4)
2. Location of land -disturbing activity: County: Harnett City or Township: Hectors Creek
Highway/Street US 401 Latitude(decimai degrees)N3527'58" Longitude(decimal degrees)W7849'43"
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): Ph3 (8.60 ACi Ph4
i 7.34 AC) 16 AC
6. Amount of fee enclosed: $ 1,600 ( ORIGINAL PAID S1 040) . 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 ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brad Haertlina E-mail Address BhaertlinaAamerican-ea.com
Phone: Office # 919-469-1101 Mobile # 919-605-5562
9. Landowner(s) of Record (attach accompanied page to list additional owners):
_KB Home Raleir_ah-Durham Inc 919-768-7972 919-427-3775
Name Phone: Office # Mobile #
4506 S. Miami Blvd. #100
Current Mailing Address
Durham NC 27703
City State Zip
City
Same
Current Street Address
State
Lip
10. Deed Book No._ See Attached Page No. 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).
KB Home Raleicih-Durham Inc
Company Name
4506 S. Miami Blvd. #100 _
Current Mailing Address
dschwartz@kbhome.com
E-mail Address
Current Street Address
Durham NC 27703
City State Zip City
Phone: Office # 919-768-7972 Mobile #
State
919-427-3775
Zip
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:
Dour; Schwartz dschwartz(cDkbhome.com
Name of Registered Agent E-mail Address
4506 S. Miami Blvd. #100 Same
Current Mailing Address Current Street Address
Durham NC 27703
City State Zip City
Phone: Office # 919-768-7972 Mobile # 919-427-3775
Doug Schwartz f Presidents
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:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
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.
n/a
Company DBA Name
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.
Doug Schwartz President
Type or print name Title or Authority
Signatafe Date
--------------- --------------------------------------------------------------------------------------------------------
I, KA &n' d ca Va ltGl�" , a Notary Public of the County of W ak-e-
State of North Carolina, hereby certify that DOU I SOhWu (fZ appeared personally
before me this day and being duly sworn ackno dged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of _ V, tkrGh , 20 Z-Z-
RACHEL CAVALEAR
, b,rlra Q COAA—A�/��
Notary Public, North Carolina
Notary
Seal Wuke County
My Commission Expires
`
My commission expires &pri
r
April 15, 2022
, ��—
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
Deed Book No.
Landowner 3 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 4 of Record:
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Phone: Office #
Current Street Address
State Zip City
Page No.
Mobile #
State Zip
Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address
City
Deed Book No.
Landowner 5 of Record:
Name
Current Mailing Address
City
Deed Book No.
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office #
Current Street Address
State Zip City
Page No.
Mobile #
state up
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.
N/A
Company 2 Name
E-mail Address
Current Street Address
Current Mailing Address
City State
Zip City State
Zip
Phone: Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
Zip City State
Zip
City State
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
Zip
City State
Zip City State
Phone: Office #
Mobile #