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HomeMy WebLinkAboutNCC231360_FRO Submitted_20230519 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 Welden - Stafford Property 2. Location of land-disturbing activity: County Forsyth City or Township Kernersville Highway/Street Stafford Country LN Latitude(decimal degrees) 36.0742 Longitude(decimal degrees) - 80.0709 3. Approximate date land-disturbing activity will commence: 04/16/2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 21.83 AC 6. Amount of fee enclosed: $2200(total for both permits). 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 I$1 No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Brent Sievers, PE E-mail Address bsievers@feiconsulting.com Phone: Office# 336-544-6432 Mobile# 9. Landowner(s) of Record (attach accompanied page to list additional owners): Welden Residential Holdings, LLC Name Phone: Office# Mobile# 418 N. Marshall Street, Suite 200 Current Mailing Address Current Street Address Winston Salem NC 27101-2979 City State Zip City State Zip 10. Deed Book No. 3727 Page No. 394 Provide a copy of the most current deed. 3727 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). Welden Residential Holdings, LLC (LINK) milt@theardengroup.com Company Name E-mail Address 418 N. Marshall Street, Suite 200 Current Mailing Address Current Street Address Winston Salem NC 27101-2979 City State Zip City State Zip Phone: Office# 919-522-0172 Mobile# 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: Parks, Stuart Name of Registered Agent E-mail Address 418 N. Marshall Street, Suite 200 418 N. Marshall Street, Suite 200 Current Mailing Address Current Street Address Winston Salem NC 27101-2979 Winston Salem NC 27101-2979 City State Zip City State Zip Phone: Office# 919-522-0172 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 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. Stuart Parks Member/Manager Type or print name Title or Authority 3-4.1- �3 Signature-' Date I, C.iivAl LA , a Notary Public of the County of State of North Carolina, hereby certify that S- 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'' day of rY pek_, , 20.23 c ,A A till yw,m4.1 Notary cl ti�rr.�✓✓.r ✓._� min9 public ti No oFors?County - My commission expires �ja-(a. 3 N�oarolina N1y Commission �Ires 12!?J2023 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. Landowner 2 of Record: PM Development, LLC Name Phone: Office# Mobile# 418 N. Marshall Street, Suite 200 Current Mailing Address Current Street Address Winston Salem NC 27101-2979 City State Zip City State Zip Deed Book No. 2531 Page No. 1160 Provide a copy of the most current deed. 2531 1168 Landowner 3 of Record: 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. Landowner 4 of Record: 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. Landowner 5 of Record: 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.