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HomeMy WebLinkAboutNCC231671_FRO Submitted_20230606 Check if this project is ARPA-funded 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, including any activity under a common plan of development of this size as covered by the NCGO1 permit, 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. ProjectNameN• First St. Townes */f this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below under which you applied for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: CountyAlamance City or Township Mebane Highway/Street N. First St. LatitUde(decimal degrees)36.3114095 Long ltude(decimaldegrees)-79.271267 3. Approximate date land-disturbing activity will commence:Summer 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 8.34 6. Amount of fee enclosed: $ 1 ,834.00 1,900 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 ❑x Enclosed D No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: NameAdam Ashbaugh E-mail AddresslashbaUgh@drbgroUp.corrl Phone: Office# 1 .919.747.4970 Mobile# 1 .919.796.5956 9. Landowner(s) of Record (attach accompanied page to list additional owners): Kirkpatrick & Associates LLC 1 .919.235.8304 Name Phone: Office# Mobile# 4004 Barrett Dr. St. 204 Current Mailing Address Current Street Address Raleigh NC 27856 City State Zip City State Zip 10. Deed Book No.4283 Page No.0929 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). DRB Group North Carolina, LLC jashbaugh@drbgroup.com Company Name E-mail Address 3000 RDU Center Dr. Ste 202 Current Mailing Address Current Street Address Morrisville NC 27560 City State Zip City State Zip Phone: Office# 1 .919.796.5956 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: 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) 2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated North Carolina Agent: Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone Fax Number (b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation, 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 Telephone Fax Number 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 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 Person). I agree to provide corrected information should there be any change in the information provided herein. gztt r vtstd.i PRieStur • DI - Type or print name Title or Authority a 3- Signature Date I, Mc.uP.400 ... C6 , a Notary Public of the County of rfeinK.ltn State of North Carolina, hereby certify that 'tiC. RbJGAS appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this 17 day of tvlUxck. , 20 2 3 ```` �1gs `ems �' �'� 0-�► ~`t-� Nota Es §9PRY p tC = My commission expires � 1--`� UBL v ';,,1 •.;'tsroi, •.• b