The URL can be used to link to this page

Home My WebLink AboutNCC233308_FRO Submitted_20231115 Check if this project is ARPA-funded Attach a copy of the Letter of Intent to Fund 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 NCG01 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. Project Name I �4-`v1 la v� M:0 -"4`,� J *If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the Division of Water Infrastructure(DWI). 2. Location of land-disturbing activity: County '^{ City or Township Pok--6c3:1 Highway/Street. aks 1y41/`/ Latitude(decimal degrees)34 3741734 LOngitUde(decimaI degrees)-80271016 3. Approximate date land-disturbing activity will commence: (- kt.! o L3 4, Purpose of development(residential, commercial, industrial, institutional, etc.): i .:iriiiieit e;:I 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): s s/ 6. Amount of fee enclosed: $ -�L 't�c' . 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 V No ❑ • 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Ve4 1. E-mail Address ('tv,LA ft k,& \\t.4.E.i,+cV „ Phone: Office# Mobile# T\C\ • 9. Landowner(s)of Record (attach accompanied page to list additional owners): Name Phone: Office# Mobile# .�,. (.11" \AI) Current Mailing Address Current Street Address City State Zip City State Zip 10. Deed Book No. I ; � Page No. r) 01 tG _Provide a copy of the most current deed. Continued from Items 9 & /0 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: 1 in i Ilonitur, 6Antis [AL R06 - 21(9 - ?VI Name Phone: Office# Mobile# 317 Pes4 416 iftect cG/14. Current Mailing Address Current Street Address CYO\W 1/4i(L, ei/t I I City State Zip CityStii14-C State Zip Deed Book No. j ff39 Page No. 3 st Provide a copy of the most current deed. • Landowner 3 of Record: Ail. ['Or& IV 3 6 7 - 69ea Name Phone: Office# Mobile# -0 . b V1C1 I Oir-kikk 1411. Current Mailing Address Current Street Address Ni5M\ r).()%0 N6-ctPfk la_ Atfr City state Zip City State Zip Deed Book No. i VS1 Page No, 0-N 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. 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 fisted as the financially responsible party(ies). ne..` GS 9th,,, t pp rily,eQ,ts,,et\ r*Q,tv4( 4,otk Company Name E-mail Address .P,t k ric' \ - cca-A 4y.i? Current Mailing Address Current Street Address City State NW, 4 L 9 I Zip City State Zip Phone: Office# A-' \ -( Ate Mobile# 1AD `1-CC- 11 l Note: If the Financially Res onsible Party is not the owner of the land to be disturbed, include with this form the landowners signs and dated written consent or -e plicant 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: 1\-GkaOL \\VC166., °kJ°, tkektr1t4irrck.03A- Name of Registered Agent E-mail/A�Address �s� '�^ Y 1 , kt \ 1 i 0 t �Y,�t iA\NA �t \c Current Mailing Address Current Street Address W L N lL alt(1 City State Zip City State Zip Phone: Office# 31(0- (g11- 6 f(90 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. i wits --tarix. PAJ51641(.t-0 Type or print Title or Authority 417ia �---� 9- // 23 Signature Date I, Cig -r- € 1y 0\P ) , a Notary Public of the County of ;fir, State of North Carolina, hereby certify that Oirt Q,Fi(1,,, }-t-Q,t-0..,) 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 1 1 day of a plikryi jet-- , 20c 3 Hover Witt • 01 '1\4 NOTARY ROJO Sumi Notary My Comm�an ' JhIZt a My commission expires 4 1 S/0Q LANDOWNER-BUILDER AGREEMENT FOR LAND DISTURBING ACTIVITIES Owner: Adela Herrera P.O. Box 1263 Dobson, NC 27017 Date of Agreement: September 11, 2023 Financially Responsible Party: Carolina Carports Inc. 187 Cardinal Ridge Trail Dobson, NC 27017 Re: New Office Construction TBD S Main St. To whom it may concern: This letter gives written consent for the a licant to submit an erosion and sedimentation control plan and to conduct he anticipated land-disturbing activity for construction of a new office building, located at TBD S. Main Street, Dobson, NC 27017. (Parcel #499507692974* Litt9S-0313S9 ). Sincerely, Name: (AI 14rftri3,. Signature: ç.] Jj 0/40,0--1 I, St-1,11114-) a Notary Public of the County o State of North Carolina, hereby certify thatOdj persona y before me this day and being duly sworn acknowledged that the above form was executed by him/her. Witness m ha artd notary seal this 11 day 062_01-ylbizr- , 203 Not My commission expires I *Off SIMI Nrf Ptauc lay Car* EigisASjal LANDOWNER-BUILDER AGREEMENT FOR LAND DISTURBING ACTMT1ES Owner: Millennium Buildings Inc. 317 W. Atkins St Dobson, NC 27017 Date of Agreement: September 11, 2023 Financially Responsible Party: Carolina Carports Inc. 187 Cardinal Ridge Trail Dobson, NC 27017 Re: New Office Construction TBD S Main St. To whom it may concern: This letter gives written consent for the applicant to submit an erosion and sedimentation control plan and to conduct the anticipated land-disturbing activity for construction of a new office buildings located at TBD S. Main Street, Dobson, NC 27017. (Parcel #499619602223). Sincerely, ..... r i.„,..i, , Name: (-- [I 4/(;t5f,44,;,/ R„I , ( 7-1 Signature: . _ .._ 1, 1—la1illtr SY) f QAN-- a Notary Public of the County ofStst.t..-MA State of North Carolina, hereby certify thateloCW aan M16-Zappeared personally before me this day and being duly sworn acknowledged that the above form was executed by him/her. Witnes my icl ,n,d notary seal this i I day ofap4trifiktkr- , 20023, My commission expires I______tionvolteue_____ 1411010111101 ' Stiny Cow* My CamMuMan Extiotifra..