HomeMy WebLinkAboutNCC230010_FRO Submitted_20230104FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Wolfspeed Temporary Substation
2. Location of land -disturbing activity: County Chatham City or Township Siler C
K
4
"-I
Highway/Street JC Teague Road Latitude(decimai degrees)35.75115 Longitude(aecimai degrees)-79.54136
Approximate date land -disturbing activity will commence: 12/12/2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.05 acres
6. Amount of fee enclosed $2,900 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed K No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Reuben Jones E-mail Address reuben.jones@duke-energy.com
Phone: Office # 919-546-3459 Mobile # 919-210-2532
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Tims Farm & Forestry, LLC XXX-XXX-XXXX XXX-XXX-XXXX
Name Phone: Office # Mobile #
7157 Bobby Jean Road 7157 Bobby Jean Road
Current Mailing Address Current Street Address
_Julian, NC 27283 Julian, NC 27283
City State Zip City State Zip
10. Deed Book No. 1729 Page No. 1027 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).
Duke Energy Progress, LLC
Company Name
410 S. Wilmington St
Current Mailing Address
Raleigh, NC 27601
City State Zip
Phone: Office # 919-546-2090
nuwan.wijesuriya@duke-energy.com
E-mail Address
410 S. Wilmington St
Current Street Address
Raleigh, NC 27601
City State Zip
Mobile # 919-931-6655
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:
CT Corporation System ct-statecommunications@wolterskluwer.com
Name of Registered Agent E-mail Address
160 Mine Lake Ct, Ste 200 160 Mine Lake Ct, Ste 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office # 919-844-8360 Mobile # N/A
Karen Rozar
Name of Individual to Contact (if Registered Agent is a company)
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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 Name
(d) If 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:
McAdams
Engineering firm or other consultant
Brandon R. Finch
Individual contact person (type or print)
finch@mcadamsco.com
E-mail Address
919-351-5000
Phone: Office #
919-210-2912
Mobile #
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.
Nuwan Wijesuriya
Lead Transmission Permitting Manager
Type or print name Title or Authority
Signature Date
I, �[r�_%�. f r•�'� •;- a Notary Public of the County of
State of North Carolina, hereby certify that /Vvwcth tt�/ 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 16 day of V . 20 4`2 7—
Wake County, North Carolina Notary
Notary Public
Celia Ann Grubba My commission expiresr%f���G°___
—ram My Commission Expires 11 /18/2026 l
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.
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:
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 4 of Record:
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:
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.
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.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
City State
Phone: Office #
Company 4 Name
Current Mailing Address
City State
Phone: Office #
Company 5 Name
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
E-mail Address
Current Street Address
Zip City State
Mobile #
E-mail Address
Zip
Current Street Address
Zip City State Zip
Mobile #