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HomeMy WebLinkAboutNCC230357_FRO Submitted_20230214NT� cq 10 S ? FINANCIAL 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 Hardee Tract Subdivision 2. Location of land -disturbing activity: County Brunswick City or Township Calabash Calabash Rd. 33.91618' -78.59997' Highway/Street_ Latitude{decimal degrees) LOngltude(decimal degrees) 3. Approximate date land -disturbing activity will commence: April 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 43 6. Amount of fee enclosed: $ 4,300.00 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 0 No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name J. Phillip Norris, P.E. E-mail Address pnorris@ntengineers.com Phone: Office # 910-287-5900 Mobile # 910-471-9638 9. Landowner(s) of Record (attach accompanied page to list additional owners); Stepping Stone NC, LLC 757-463-5000 Name 448 Viking Drive, Suite 220 Current Mailing Address Virginia Beach VA 23452 Phone: Office # 757-510-4234 Mobile # 448 Viking Drive, Suite 220 Current Street Address Virginia Beach VA 23452 City State Zip City 10. Deed Book No. 4634 Page No.1100 State 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.) !f the company is a sale 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). Stepping Stone NC, LLC Company Name 448 Viking Drive, Suite 220 Current Mailing Address Virginia Beach VA 23452 City State Zip Phone: office # 757-463-5000 raymond@lmssi.com E-mail Address 448 Viking Drive, Suite 220 Current Street Address Virginia Beach VA 23452 City State Zip Mobile # 757-510-4234 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: CT Corporation System Name of Registered Agent 160 Mine Lake Ct, Ste 200 Current Mailing Address Raleigh NC 27615 City State Zip Phone: Office # 757-463-6026 Brittney Willis NIA E-mail Address 160 Mine Lake Ct, Ste 200 Current Street Address Raleigh NC 27615 City State Zip Mobile # 757-510-4234 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-in4act, 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. Raymond L. Gottlieb Type or print name Signature Stepping Stone NC, LLC By- TMPR,_LLG, its Manager Title or Authority Raymond Gottlieb, Manager, TMPR, LLC %2 S / '-�3)j Date 5kGk a Notary Public of the County of UG . (Se" Vir I`wtiL. I - ila`7 r State of hereby certify that ��-j►�^� 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 , 20aa VZOZ iE IGBO.LDO S3'IIdX3 NOISSIWWOO AW el �o yaleaMuawui00 66TZ # '931d 0!lgnd tie4oN )IueL4s .O e!yjwlg 9. UC4� Notary-) My commission expires I LOI3f��3)-L'(