HomeMy WebLinkAboutNCC230514_FRO Submitted_20230224FINANCIAL 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 NIA in the blank.)
Part A.
1. Project Name UNC McColl Bldg Addition and Renovation (MBAR)
2. Location of land -disturbing activity: County Orange City or Township Chapel Hill
Highway/Street Latitude(decimal degrees) William Blythe Drive 9 ) 35.900771 Long ltude(decimaidegrees) -79,046946
3. Approximate date land -disturbing activity will commence: December 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 9 acres
6. Amount of fee enclosed $2,900.00 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, after which 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJanet Clarke
Phone: Office # (919) 843-0475
E-mail Address jlclarke@ehs.unc.edu
Mobile # (919) 883-7163
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The University of North Carolina at Chapef Hill (919) 962-3795
Name Phone: Office #
Campus Box 1005
Current Mailing Address
Chapel Hill
City
10. Deed Book No. W B 1
NC 27599-1005
State Zip
123 West Franklin St
Current Street Address
NIA
Mobile #
Chapel Hill NC 27516
City
State
Zip
Page No. 36 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 landowners) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
The University of North Carolina at Chapel Hill
Company Name
Campus Box 1005
Current Mailing Address
Chapel Hill NC 27599-1005
City State Zip
Phone: Office # (919) 962-3795
gbattleaa ad.unc.edu
E-mail Address
123 West Franklin St
Current Street Address
Chapel Hill NC 27516
City State Zip
Mobile # N/A
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
Current Mailing Address
E-mail 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
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
State Zip
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:
NV5 Engineers + Consultants
Engineering firm or other consultant
Jonathan Allen
Individual contact person (type or print)
Jonathan.Allen@nv5.com
E-mail Address
919-858-1831 919-924-2510
Phone: Office # 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.
George E. Battle, III
Vice Chancellor of Institutional Integrity and Risk Management
Type or print name Title or Authority
Signat a Date
I, l-ajU Gl X a Notary Public of the County of yVake,
State of North Carolina, hereby certify that r�1% C �+�� �� 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 -I day of NOVeWl20 22
Seal
_q4�7A&X --n _*"
Notary
My commission expires. D r o o 0 —2q
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:
Name
Current Mailing Address
City State
Deed Book No.
Landowner 3 of Record:
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office # Mobile #
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
Current Mailing Address
C ity
Deed Book No.
Landowner 5 of Record:
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office # Mobile #
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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip