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HomeMy WebLinkAboutNCC231710_FRO Submitted_20230605 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 NameAMICO RESIDENCE 2. Location of land-disturbing activity: County Polk City or Township Mill Spring 189 South Cove Road 35.3241 -82.1944 Highway/Street Latitude(decimal degrees) Longitude(decimai degrees) 3. Approximate date land-disturbing activity will commence:April 1 , 2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 ACRE 6. Amount of fee enclosed: $ 100.00 . 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 I] Enclosed i] No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Michael Amico E-mail Address michaelpaulamico@gmail.com Mobile# 954-536-0592 Phone: Office# N/A 9. Landowner(s)of Record (attach accompanied page to list additional owners): Michael Amico N/A 954-536-0592 Name Phone: Office# Mobile# 705 New York St., Apt. 1 705 New York St., Apt. 1 Current Mailing Address Current Street Address West Palm Beach, FL 33401 West Palm Beach, FL 33401 City State Zip City State Zip Page No.2394 10. Deed Book No.457 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). Michael Amico michaelpaulamico@gmail.com Company Name E-mail Address 705 New York St., Apt. 1 705 New York St., Apt. 1 Current Mailing Address Current Street Address West Palm Beach, FL 33041 West Palm Beach, FL 33041 City State Zip City State Zip Mobile# 954-536-0592 Phone: office# 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 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: Keith Brown kbrown@americashomeplace.com Name of Registered Agent E-mail Address 462 Weaverville Rd 462 Weaverville Rd Current Mailing Address Current Street Address Asheville, NC 28804 Asheville, NC 28804 City State Zip City State Zip Phone: Office# 864-849-0880 Mobile# N/A 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. N/A 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. Michael P Amico Owner Type or print n ri7e) , Title or Authority c,..4 Signature Date I, -1A0(ri s 7 (jordOrmrrJ , a Notary Public of the County of foilri eArh rlor �1 State of-North Carulir,a, hereby certify that /Y7/(/cap / P /tn7jtO 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 // day of M ' , 20_e otary 74 My commission expires /'IGrre/% ) rIllriereiglhalikalhuftmaNamiandandho I u}Y pu THOMAS M BORDONARO `F•. Notary Public•State of Florida A `? Commission#HH 369915 af,cf My Comm.Expires Mar 28,2027 Notarization validates Bonded through National Notary Assn. I signature only, not document content 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: Erin Stearns Amico N/A 954-701-8411 Name Phone: Office# Mobile# 705 New York St., Apt. 1 705 New York St., Apt. 1 Current Mailing Address Current Street Address West Palm Beach, FL 33401 West Palm Beach, FL 33401 City State Zip City State Zip Deed Book No.457 Page No.2394 Provide a copy of the most current deed. Landowner 3 of Record: N/A 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: N/A 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: N/A 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. Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties. Attach copies of this page as needed to list all financially responsible parties. N/A Company 2 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# N/A Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# N/A Company 4 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# N/A Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile#