NCC222896_FRO Submitted_20220812

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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 NIA in the blank )
Part A.
1. Project Name Fieldview Village Estates
2.
Location of land -disturbing activity: CountyJohnSton
City or Townshi
HighwaylStreet 1 162 Latitude 35.45219 Longitude,
3. Approximate date land -disturbing activity will commence: ASAP
Four Oaks
K-50MO
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 25.15 26x $i00=$2,600
4,600 EXPRESS=$2,000
6. Amount of fee enclosed: $ The Express Permitting application fee is a dual _
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name It,. f-f cZ.J�-- /E-mail Address r y� � ��i •Cc �7
Telephone Cell #t `1�11 �SGtS-IZYii Fax
9 Landowner(s) of Record (attach accompanied page to list additional owners):
C&B Development, LLC 919-868-1508
Name Telephone
2880 Elevation Road 2880 Elevation Road
NIA
Fax Number
Current Mailing Address Current Street Address
Four Oaks, NC 24524 Four Oaks, NC 24524
City State Zip City State Zip
10. Deed Book No. 06259 Page No. 788 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 orfirm is a sole proprietorship,
ImA�J
e name of the owner or manager may be listed as the financially responsible party.
I S� L.LC. rry QU ZZ r•
Name E-mail tddress
lid � ray 11l c Q4
Current Mailing Address Current Street Address
t`k _ k 13 ti
City �} State Zip City ; State Zip
Telephone Fax Number

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:
NIA NIA
Name
NIA
Current Mailing Address
N/A
City State
Telephone NIA
E-mail Address
NIA
Current Street Address
N/A
Zip City
Fax Number NIA
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:
N/A
N/A
Name of Registered Agent
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A
NIA
City State Zip
City State Zip
Telephone N/A
Fax Number N/A
(c) In order to facilitate Express Permitting, it
is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Adams and Hodge Engineering, PC
[e-mail]
Engineering Firm or other consultant
E-mail Address
Amanda Grimm
513-325-3192 NIA
Individual contact person (type or print)
Telephone 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.
Uz"� NI NW ti 1V_ 14- 1 L WRV--�fffi\ LLe,
ype or prin a Title or Au hori y
I _rT 22-
Signature Date
I, 1` lcC U+_sor� 5�ct f� a Notary Public of the County of —Ldc
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand an�,�91,90M�seal, this _day of �V , p 2 Z
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Notiry Public � = NO ry
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County I y My commission expires 1 f LZZC.2- S
My COMM,
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