The URL can be used to link to this page

Home My WebLink AboutNCC231784_FRO Submitted_20230609 F|NANCIALRESPONSUBULITY1OWNERSH(P FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION No person nnoyinijuteany|ond-disturbingactivityononaorrnoneacremmmcuvaredbytheActbefonsthiafonn and an acceptable erosion and sedimentation control plan have been completed and approved bythe Land Quality Section, N.C. Deportment 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 o, phone number io unavailable, place N/A in the b|mnk.) Part A. 1. Project Nome Lot 576 B[OQkberry 2. Location of land-disturbing activity: County F[Q'8Vfh _ � City or Township Winston-Salem ��m�� 1�� H ^^'��^`�� Farr �� z «f/~uya��m� 'x ' ' LmUtudo�eumm�mn�, ^/`�_ /^^�Longitudemem^��e� -°^^'°^ - 3. Approximate date land-disturbing activity will commence: 6/12/2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.): residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): '30 1OO 9. Annountof fee enclosed '"° . The Express Permitting application fee ioo dual charge. The normal fee of$1OO.O0 per acre (rounded upto the next acre) io assessed without o ceiling amuun1 /naddi�on.the Express PernnihUngsupplan�entim$25O per acre upto eight acres,after which the Express - Permitting supplemental fee iaa fixed$2.00O.OD (Exannp/e:8.10'aura application fee ia$2.QUO) Cheuk- uhou|dbeaddnaooedtoNCOEQ. 7. Has mn erosion and sediment control plan been filed? Yes Enclosed El No 17 8' Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Geoffrey &0't�h��|| (��(��\[�'f��O�U�fC>0�~ �-mail ''«��Mitch ` ^^ Phone' O�ue# �43��-{�93-/1�� -��Mi-�� . - -- �obi|a# °"° "° ` ~'=°° &. Landowner(s) of Record (attach accompanied page to list additional owners): Mary-Ann Fegan 9197410770 Name Phone: Offioa# Mobile# Current Mailing Address Current Street Address Coy State Zip City State Zip OR�1��1 R�1�� 10. Deed Book No. °°^^ ,^^�` Page No. "' ,"° Provide a copy of the most current deed. Part2. 1. Compmnv(iem)who are financially responsible for the land-disturbing activity(Provdeaoon�pnshenm�e|�t cfaO responsible porhemonmocornAoniedpmge ) ��e /� so� ' e»md/wd«a��. the name�)of the omme,�)/neybe�s�da^""�°«y/ ^'s p«4�«e�omYz»r�8/e/andomme��n x the financially responsible pany(ieq). M'frhco Inc. �� [��(3ffX��'tchcC}cUsfCJ��`U'|'��rs.C�O�� Company Name �� - E-mail Address � 1111 S Marshall st. Unit 172 Current Mailing Address Current Street Ad dress VV'nsfnn Salem NC 27101 City 'State - ua Zip CityGtate Zip ��_O��-�� 1 Phone: ��oe# ~�" "��—`�"= �obUe# a�«�-�U '-58D8 Note: If the Financially Responsible Party ia not the owner of the land 1obodisturbed udahthimh�nn the|andovvne� written �u`~~'~^~^ with this 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: C)Mice# Mobile# Name of Individual to Contact(if Registered Agent is moompany) (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: Offioe# Mobile# Name of Individual to Contact(if Registered Agent ioacompany) (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: Engineering firm or other consultant E-mail Address 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. Geoffrey Mitchell President Type or print na e Title or Authority Signature Date I, 1.-(6d4 0 iii.14-C h . I I , a Notary Public of the County of EDV. 11-1t-N State of North Carolina, hereby certify that er-drie It'?e-chc I ( appeared personally before me this day and being duly sworn acknowledge that the above form was executed by him/her. Witness my hand and notarial seal, this r7 day ofj(-114e- , 20 2 3 No1ry 1/1444-) oa, .70) Seal ,e „fa. iviir,-,,,, '‘' My commission expires q/2.--I I 2.0 .• pr:.•-- Z .• ..•.:•( ''', :...* vN'../ \OTA 1.4."•.( "is Z : •• 0 . • . . . • er.•--rz • el I. . ; ... ; 0'11%.. 41/B .: 4' O° il& 4: ...*. ## k9i,. •.........."%ck sNS. 44...sgiss°