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HomeMy WebLinkAboutNCC230974_FRO Submitted_20230414 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 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 The Village at Compass Pointe Section 1 2. Location of land-disturbing activity: County Brunswick City or Township Leland Compass Pointe South Wynd NE 34.271490 -78.108851 Highway/Street Latltude(decimal degrees) Longitude(decimal degrees) _ 3. Approximate date land-disturbing activity will commence: Upon Permit Receipt 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 1'74 6. Amount of fee enclosed: $ 1'200 . 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 El Enclosed El No 0 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Jon Epstein E-mail Address jepstein@sr-rep.com Phone: Office# Mobile# (914) 826-0280 9. Landowner(s) of Record (attach accompanied page to list additional owners): SR Compass Pointe LLC (914) 826-0280 Name Phone: Office# Mobile# 4 West Red Oak Lane, Suite 325 4 West Red Oak Lane, Suite 325 Current Mailing Address Current Street Address White Plains NY 10604 White Plains NY 10604 City State Zip City State Zip 10. Deed Book No.4772 Page No.637 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). SR Compass Pointe, LLC jepstein@sr-rep.com Company Name E-mail Address 4 West Red Oak Lane, Suite 325 4 West Red Oak Lane, Suite 325 Current Mailing Address Current Street Address White Plains NY 10604 White Plains NY 10604 City State Zip City State Zip Phone: Office# Mobile# (914) 826-0280 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 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: Marc L. Isaacson marc@isaacsonsheridan.com Name of Registered Agent E-mail Address 804 Green Valley Road 804 Green Valley Road Current Mailing Address Current Street Address Greensboro, NC, 27408-7044 Greensboro, NC, 27408-7044 City State Zip City State Zip Phone: Office# (336) 609-5134 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. Jon Epstein Partner Type or p 'fit me Title or Authority 7/2-7A0 Z- Signat a Date I, kCjiiv l< e el P. , a Notary Public of the County of iU)'(C\r\Q,SS State of Nurtti Earvfma, hereby certify that ----SbY1 a 'K-1 tdN appeared personally before me this day and being duly sworn acknowledged th t the above form was executed by him/her. Witness my hand and notarial seal, this ��` day of Sv�� , 20 2y Notary My commission expires KATHLEEN P.30E Notary Public,State of New York No.01B0b021974 Qualified in Duchess Cerin Term Expires March 22,20 �7