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HomeMy WebLinkAboutNCC230835_FRO Submitted_20230328Check if this project is ARPA-funded ❑ 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, including any activity under a common plan of development of this size as covered by the NCG01 permit, 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 Creekside Cottages *If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below under which you applied for funding through the Division of Water Infrastructure (DWI). 2. Location of land -disturbing activity: County Gaston City or Township Bessemer City Costner School Rd 35.2986-81.2596 Highway/Street LatltUde(decimaldegyees) LOngltude(decimal degrees) 3. Approximate date land -disturbing activity will commence: 04-01-2023 4 6i Purpose of development (residential, commercial, industrial, institutional, etc.): Residential Total acreage disturbed or uncovered (including off -site borrow and waste areas): 55.6 6. Amount of fee enclosed: $ 5,600 . 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 ❑ No ❑x 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Jon Haston E-mail Address Jon•Haston@Lennar.com Phone: Office # Mobile # 980-395-5632 9. Landowner(s) of Record (attach accompanied page to list additional owners): BBB&C ENTERPRISES LLC Name P O BOX 845 Current Mailing Address CHERRYVILLE, NC 28021-0845 City 10. Deed Book No. 4768 Phone: Office # Current Street Address State Zip City Page No. 2316 Mobile # 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.) 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). Lennar Carolinas, LLC Company Name 6701 Carmel Road, Suite 425 Current Mailing Address Charlotte, NC 28226 City State Phone: Office # 704-759-600 E-mail Address 6701 Carmel Road, Suite 425 Current Street Address Charlotte, NC 28226 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: Lennar Carolinas, LLC Name of Registered Agent 6701 Carmel Road Current Mailing Address Charlotte, NC 28226 City State Phone: Office # 704-759-6000 Mark Henninger Zip mark. henninger@lennar.com E-mail Address 6701 Carmel Road Current Street Address Charlotte, NC 28226 City State Zip 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 Phone: Office # E-mail Address Current Street Address State Zip City State Zip 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. x /ffUX E,�.vaGttL k Vic,t. Type or print nam Title or Authority Signature Date a Notary Public of the County of U "/) i State of North Carolina, hereby certify that it e.-(— 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 2-3 day of20_gL3__ KATHLEEN G. JONES NOTARY PUBUC Notary Union County / " North Carolina /(� / � 7 My Commission Expires M �t, 2027�� My commission expires _� 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. Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Name Current Mailing Address City Deed Book No._ Name Current Mailing Address City Deed Book No._ Name Current Mailing Address City Deed Book No. 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 State Zip City State Zip Page No. Provide a copy of the most current deed. Phone: Office # Mobile # Current Street Address State Zip City State Zip Page No. Provide a copy of the most current deed. Continued from Item 1 in Part 8 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 Current Mailing Address City Phone: Office # E-mail Address Current Street Address State Zip City Mobile # Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip City Phone: Office # Mobile # State Zip State Zip 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