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HomeMy WebLinkAboutNCC230030_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. Project Name Harold J. Perkins and Adrienne R. Perkins 2. Location of land -disturbing activity: County Caldwell City or Township Lovelady Highway/Street Plantation Pt. Dr. Latitude,deamal degrees; 35.7982 Longitude(decimal degrees) 81.3424 3. Approximate date land -disturbing activity will commence: mid December 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Kesiaentiai 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.14 6. 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. 7. Has an erosion and sediment control plan been filed? Yes Enclosed X. No 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name John Sprinkle E-mail Address johnasprinkle@gmail.com Phone: Office # Mobile # (828) 217-2933 9. Landowner(s) of Record (attach accompanied page to list additional owners): Harold J. Perkins Name Phone: Office # 130 Hunters Hill Dr. 130 Hunters Hill Dr. Current Mailing Address Current Street Address Statesville NC 28677 Statesville NC City State Zip 10. Deed Book No. 2006 Page No. City 2158 State (281) 731-6477 Mobile # 28677 Zip 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). Harold J and Adrienne R. Perkins arperkins2008@comcast.net Company Name 130 Hunters Hill Dr. E-mail Address 130 Hunters Hill Dr. Current Mailing Address Current Street Address Statesville NC 28677 Statesville NC 28677 City State Zip City State Zip Phone: Office # Mobile # (281) 731-6477 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 Phone: Office # Mobile # 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. 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. Harold J. Perkins T or print m Signature Property Owner Title or Authority /l1.2-y /.1 C) Z2— Date a Notary Public of the County of State of North Carolina, hereby certify that Id J j erL r''T } 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 ,L�7 "day of Nt"�z""' � 20 �= 11/NIIIINM O"�GOfy"• Nota .� �.,___.,2q '''+y, rY tSION GQ• �OTA/�y s My commission expires << cod,, 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. Landowner 2 of Record: Adrienne R. Perkins (281) 608-8644 Name Phone: Office # Mobile # 130 Hunters Hill Dr. 130 Hunters Hill Dr. Current Mailing Address Current Street Address Statesville NC 28677 Statesville NC 28677 City State Zip City State Zip Deed Book No. 2006 Page No. 2158 Provide a copy of the most current deed. Landowner 3 of Record Name Current Mailing Address City Deed Book No._ Landowner 4 of Record: Phone: Office # Mobile # Current Street Address State Zip City State Zip Page No. Provide a copy of the most current deed. Name Phone: Office # Mobile # Current Mailing Address City Deed Book No.- -, n — - , G -f D---, 4 Name Current Mailing Address City Deed Book No. Current Street Address State Zip City State Zip Page No. Provide a copy of the most current deed. Phone: Office # Mobile # Current Street Address State Zip City Paqe No. State Zip Provide a copy of the most current deed.