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HomeMy WebLinkAboutNCC233494_FRO Submitted_20231205 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 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. Project Name Coats Baptist Church *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). N/A 2. Location of land-disturbing activity: County Harnett City or Township Coats NC 55 W(N McKinley St) 35.415456 -78.673503 Highway/Street Latitude(decimal degrees) LongitUde(decimal degrees) 3. Approximate date land-disturbing activity will commence: 12/1/23 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Church / Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10 AC 6. Amount of fee enclosed: $ 1 ,000.00 . 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 ❑ Enclosed El No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Danny Stevens (Properties Chairman) E-mail Address danny.stevens42@gmail.com Phone: Office# Mobile# 919-279-7063 9. Landowner(s)of Record (attach accompanied page to list additional owners): Coats Missionary Baptist Church 919-279-7063 Name Phone: Office# Mobile# PO Box 297 554 North McKinley Street Current Mailing Address Current Street Address Coats NC 27521 Coats NC 27521 City State Zip City State Zip 10. Deed Book No. 3336 Page No.0949 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)maybe listed as the financially responsible party(ies). Coats Missionary Baptist Church danny.stevens42@gmail.com Company Name E-mail Address PO Box 297 554 North McKinley Street Current Mailing Address Current Street Address Coats NC 27521 Coats NC 27521 City State Zip City State Zip Phone: office# Mobile#919-279-7063 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: Henry Holmes Name of Registered Agent E-mail Address PO Box 297 600 N McKinney St Current Mailing Address Current Street Address Coats NC 27521 Coats NC 27521 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) (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 o -Assumed Na e. 1/ ' -r am c1 6,4705 .;/eletAxiL./. rllpany i A fume 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 provid herein. ite y or pri ame Tit e or uthorit l/v 2°2`3 lure ` Date I, --727./Lt-,gc 21../4,9 E a Notary Public of the County of Ti/i}4 n/s State of North Carolina, hereby certify that Tji/nl 5TE MA'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/y14 day of S[Pi Al.elE,� , 20 23 .1 • . NotaP1421- G4/" deal `6� My commission expires y/ (o