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HomeMy WebLinkAboutNCC230904_FRO Submitted_20230331FINANCIAL 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 NameRidgernont Lot EC Plan 2. Location of land -disturbing activity: County Davie City or Township Mocksyllle Highway/StreetWhitneY Latitude(decimal degrees) rd. 35.9037 Long itude(decima;degrees)-80.5217 3. Approximate date land -disturbing activity will commence: January 2022 4. 5. 6. 7. 8 Purpose of development (residential, commercial, industrial, institutional, etc.) Residential Total acreage disturbed or uncovered (including off -site borrow and waste areas):4.0 Amount of fee enclosed: $400 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 David Harr E-mail Address David.Harr@centurycommunities.com Phone: Office # N/A Mobile # 336-314-0974 9. Landowner(s) of Record (attach accompanied page to list additional owners): WJH LLC N/A Name Phone: Office # N/A Mobile # 3091 Governors Lake Dr, STE 300 3091 Governors Lake Dr, STE 300 Current Mailing Address Current Street Address Norcross GA 30071 Norcross GA 30071 City State Zip City State Zip 10. Deed Book No 1227 Page No. 80-8 3 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). WJH LLC Company Name 3091 Governors Lake Dr, STE 300 Dave.Hodgman@centurycommunities.com E-mail Address 3091 Governors Lake Dr, STE 300 Current Mailing Address Current Street Address Norcross GA 30071 Norcross GA 30071 City State Zip City State Zip Phone: Office # 336-362-6211 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: N/A N/A Name of Registered Agent E-mail Address N/A N/A Current Mailing Address Current Street Address N/A N/A City State Zip City State Zip Phone: Office # N/A Mobile # N/A 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 CT@ctmail.wolterskluwer.com Name of Registered Agent E-mail Address 160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200 Current Mailing Address Raleigh, NC 27615 City State Zip Phone: Office # 855-374-0404 N/A Current Street Address Raleigh, NC 27615 City State Zip Mobile # N/A 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. Dave Hodgman Regional President Type or print Title or Authority Signature — Date a Notary Public of the County of State of North Carolina, hereby certify that DC, .,e HO . appeared personally before me this day and being duly sworn acknowledged that tl a above form was executed by him/her, Witness my hand and notarial seal, this day of 'L I-CFN%Lx/- 20�. otary My commission expires cibLolf Priscilla R. Bravo NOTARY PUBLIC ' Guilford County, NC My Commission Expires September 18, 2027