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HomeMy WebLinkAboutNCC230758_FRO Submitted_20230321FINANCIAL 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 NIA in the blank.) Part A. 1. Project Nam V1 3. 4. 5. 6. 7 8 0 Waterleig h Phase 2 Conservation Subdivision (C� Location of land disturbing activity: County Currltuck City or Township Moyock Tulls Creek Rd 36,52267 76.14336 HighwaylStreet Lat�tude(decimal degrees? LOngltude(decimal degrees) Approximate date land -disturbing activity will commence: August 2022 Purpose of development (residential, commercial, industrial, institutional, etc.): Residential Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.65 Acres Amount of fee enclosed: $ 800.00 . 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 ❑ Enclosed x❑ No ❑ Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Terry Drew E-mail Address Terry@cheshomes.com Phone: Office # 7576718700 Mobile # 7574490613 Landowner(s) of Record (attach accompanied page to list additional owners): Waterleigh NC, LLC 7574635000 Name Phone: Office # 448 Viking Dr. Ste 220 same as mailing Current Mailing Address Virginia Beach VA 23452 Current Street Address nla Mobile # City State Zip City State Zip 10. Deed Book No. 1705 Page No. 243 Provide a copy of the most current deed. 1 � @ T 0 T � DEC 302022 IU 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). Chesapeake Homes of North Carolina., A( , Company Name E-mail Address 448 Viking Dr. Ste 220 same as mailing Current Mailing Address Current Street Address Virginia Beach VA 23452 City State Phone: Office # 7576718700 Zip City Mobile # State Zip 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 AddressIN nEC 3 Current Mailing Address Current Street Address B y City State Zip City State 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 E-mail Address 160 Mine Lake Ct. Ste 200 same as mailing Current Mailing Address Raleigh NC 27615-6417 City State Zip Prone: Office # Current Street Address City 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. Raymond Gottlieb Type or print namef i Signature Manager Title or Authority Date I, �• S � a Notary Public of the County of HNC•{ &e'ct, V l �5i nfG.. r State of Alar4-Qa;Q4�a, hereby certify that ►k� L , (;rfv,6' � 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 cxn day of 20aa ECynthia G. Shank Notary Public REG. * 213972 Commonwealth of Virginia MI55IQN EXPIRES OCT06ER 31 2024 Nota My commission expires 14 a, �n oEc so2oz2