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HomeMy WebLinkAboutNCC224039_FRO Submitted_20221207FINANCIAL 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 Heartsease at Calabash 2. Location of land -disturbing activity: County Brunswick City or Township Calabash Persimmon Road (SR 1167) 33.9055-78.5702 Highway/StreetLatltude(decimal degrees) LOngltude(decimal degrees) 3. Approximate date land -disturbing activity will commence: Upon receipt Of permit 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)- NA 6. Amount of fee enclosed 5 NA 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 ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: NameAndy Smith E-mail Address andy 9 eyccom pan ies Phone: Office # 843.588.5021 Mobile # NA 9 Landowner(s) of Record (attach accompanied page to list additional owners): Heartsease Calabash, LLC 843.588.5530 NA Name 6837 Falls of Neuse Road, Suite 208 Current Mailing Address Raleigh, City 10. Deed Book No. 4923 Phone: Office # Mobile # 6837 Falls of Neuse Road, Suite 208 Current Street Address NC 27615 Raleigh, NC 27615 State Zip City Page No. 0766 State Zip Provide a copy of the most current deed. Part B. I- 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). Heartsease Calabash, LLC Company Name 6837 Falls of Neuse Road, Suite 208 Current Mailing Address Raleigh, NC 27615 City State Phone: Office # 843.588.5530 andy@eyccompanies E-mail Address 6837 Falls of Neuse Road, Suite 208 Current Street Address Raleigh, NC 27615 Zip City Mobile # NA State 52 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: Heartsease Calabash, LLC Ellis@eyccompanies.com Name of Registered Agent E-mail Address 6837 Falls of Neuse Road, Suite 208 6837 Falls of Neuse Road, Suite 208 Current Mailing Address Raleigh, NC 27615 City State Zip Current Street Address Raleigh, NC 27615 City Phone: Office # 843.588.5530 Mobile # NA Ellis Coleman 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: NA Name of Registered Agent NA Current Mailing Address NA City Phone: Office # NA NA NA E-mail Address NA Current Street Address NA State Zip City Mobile # NA 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. NA 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. Ellis Colem Type or prin Sig Principal Title or Authority s D2 Date or I, S a Notary Public of the County of C State of North Carolina, hereby certify that �- [�L�'��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 , 20 '2- —2� SARAH NIENHAUS Notary Public, State of South Carolina My Commisslon Expires 2/10/2026 NoWy My commission expires �� 2�