HomeMy WebLinkAboutNCC230791_FRO Submitted_20230404 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
No person may initiate any land-disturbing activityone-or more ae sd ere liy the Act before thislopri
and an acceptable erosion and sedimentation control plan hav een.compeIeted and-\pproved by the Lad'
Quality Section, N.C. Department of Environmental Quality. Sub?0,f le_completed forp, to,the appropriatC
Regional Office. (Please type or print and, if the question is not ar4tec,lbJe or,e-m'alf ac14j or-phone\j�
number is unavailable, place N/A in the blank.) �N' J� mL'°.<; '
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Part A. 'o')
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1. Project Name
HICKORY METRO CONV CENTER AbDITION
CATAWBA HICKORY
2. Location of land-disturbing activity: County City or Township
1960 13TH AVE DR SE 35.7$C1‘)\ -81.30 \
Highway/Street Latitude(declmal degrees) Longitude(depmaI degrees)
QIAMISPOLli
3. Approximate date land-disturbing activity will commence: fil" 12/01/22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): COMMERCIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.59
6. Amount of fee enclosed $400+$1000 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
WILLIAM CLAYTON WCLAYTON@CLAYTON-ENGINEERING.NETE-mail Add
dress
Phone: office# Mobile# 828-455-3456
9. Landowner(s)of Record (attach accompanied page to list additional owners):
CITY OF HICKORY 828-323-7412
Name Phone: Office# Mobile#
PO BOX 398
Current Mailing Address Current Street Address
HICKORY NC 28603
City State Zip City State Zip
10. Deed Book No.2123 Page No. 0054 Provide a copy of the most current deed.
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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).
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Company Name E-mail Address
Pb (lox 3111 —�
Current Mailing Address Current Street Address
141404 NIG Z96o3
City State �/ Zip City State Zip
Phone: Office# 818-�s-7y/L Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowners 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:
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)
(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:
CLAYTON ENGINEERING & DESIGN WCLAYTON@CLAYTON-ENGINEERING.NET
Engineering firm or other consultant E-mail Address
WILLIAM CLAYTON 828-455-3456 SAME
Individual contact person (type or print) 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.
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Type or print name Title or A'bthority
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Signature Date
I, Dei5y Zavala UaZQUtZ , a Notary Public of the County of 130r Re
State of North Carolina, hereby certify that Wa rr&h IA/ODid 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 16 day of AU us 4 , 20 Z 2
C)eviv" Burke County,North Carolina '� 124'"""'
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NotaryPublic ry
ti D%g9IZavala Vazquez My commission expires 0 L/ -al - Z_3