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HomeMy WebLinkAboutNCC222946_FRO Submitted_20220817FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.) Part A. 1. Project Name Emerson Hills Apartment Homes 2. Location of land -disturbing activity: County cabarrus City or Township Kannapolis Highway/Street N. Ave. Extension Latitude N 35 27' 21° Longitude W 80 35' 56° 3. Approximate date land -disturbing activity will commence: 05/01/21 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off - site borrow and waste areas): 28.5AC*r 6. Amount of fee enclosed: $ 1885.00 . 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 Kara Strickland E-mail Address kstrickland@pedcor.net Telephone (317) 218-2683 Cell # Fax # E Landowner(s) of Record (attach accompanied page to list additional owners): Pedcor Investments, A Limited Liability Company 317.587.0320 Name Telephone 770 3rd Ave., S.W. 770 3rd Ave., S.W. Current Mailing Address Current Street Address Carmel IN 46032 Carmel IN City State Zip 10. Deed Book No. 14707 Page Part B. City State 317.587.0340 Fax Number 46032 Zip 0013-0027 Provide a copy of the most current deed. 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. Pedcor Investments-2020-CXXIX, L.P. mbyron@pedcor.net Name E-mail Address 770 3rd Ave., S.W. 770 3rd Ave., S.W. Current Mailing Address Current Street Address Carmel IN 46032 Carmel IN 46032 City State Zip City State Zip Telephone 317.587.0320 Fax Number 317.587.0340 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: McKenzie Pulicover McKenzie.Publicover@kimley_horn.corn Name E-mail Address 200 Tryon St., Suite 200 200 Tryon St., Suite 200 Current Mailing Address Current Street Address Charlotte NC 28202 Charlotte NC 28202 City State Zip City State Zip 704.333.5131 N/A 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: Corporation Service Company NIA Name of Registered Agent E-mail Address 2626 Glenwood Ave., Suite 550 2626 Glenwood Ave., Suite 550 Current Mailing Address Current Street Address Raleigh NC 27608 Raleigh NC 27608 City State Zip City State Zip Telephone 800.927.9800 Fax Number N/A 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. Jared M. Houser Senior Vice President Type or prin ame Title or Authori 4__iature Date ----------------------------- I ------------------------------------------------------------------------------------------------- I, {CFI ilVl Bynds , a Notary Public of the County of rl State of INVIt�E e Icj hereby certify that ���Y� i M Ski appeared 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 *day of � _ 2020 P! ' CAITLIN BURGESS ['J ,o�pPY PG�f�` Notary Public, State of Indiana =z SEAL;^= f3ooneCounty Notary CommissionNumberNP0719538 p`?bin'k y Commission Expires P.� M April 02, 2027 My commission expires kn