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HomeMy WebLinkAboutNCC230053_FRO Submitted_20230110FINANCIAL 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 3. 4. 5. 6. 7 Project Name Currituck County Public Works Maintenance Building Location of land -disturbing activity: County Currituck City or Township Maple Township Airport Road 36.398956-76.012293 Highway/Street Latltude(decimal degrees} LOngitude(decimal degrees) Approximate date land -disturbing activity will commence: January 3, 2023 Purpose of development (residential, commercial, industrial, institutional, etc.); institutional Total acreage disturbed or uncovered (including off -site borrow and waste areas}: 1.9 ac Amount of fee enclosed: $ 200.00 . 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. Has an erosion and sediment control plan been filed? Yes 0 Enclosed 0 No ❑ Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Jim Vachon E-mail Addressjvachon@sussexdevelopment.com Phone: Office # 757-422-2400 Mobile # 757-636-0548 9. Landowner(s) of Record (attach accompanied page to list additional owners): Currituck County 252-232-2075 Name 153 Courthouse Road, Suite 204 Phone: Office # Mobile # 153 Courthouse Road, Suite 204 Current Mailing Address Current Street Address Currituck NC 27929 Currituck NC 27929 City State 10. Deed Book No. 875 Zip City Page No. 807 State 22 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). Currituck County Ike.Mcree@CurrituckCountyNC.gov Company Name 153 Courthouse Road, Suite 204 Current Mailing Address Currituck NC 27929 City State Zip Phone: Office # 252-232-2075 E-mail Address 153 Courthouse Road, Suite 204 Current Street Address Currituck NC 27929 City State Zip Mobile # 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: 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) (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 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. Donald I. McRee, Jr. County Manager ror pri t ame Title or Authority �klgoure Date ..------_........ ------- ---------- ------------------------------------- _.------------------------------------ ---------------------- 1 �6^MQ In - EVOM S a Notary Public of the County of State of North Carolina, hereby certify that ojd T •m( r• appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him/her. JV Witness my hand and notarial seal, this I (day of t VV ,t%U(Xr' , 20 3 a otary My commission expires SAMANTHA M. EVANS } Notary Public, North Carolina Currituck County My Com fission pires G