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HomeMy WebLinkAboutNCC233447_FRO Submitted_20231211 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 and/or fax information unavailable, place N/A in the blank.) Part A. 1. Project Name: Kamdon Ranch—EC Plan for Lots 49-53 2. Location of land-disturbing activity: County: Johnston City or Township: Hectors Creek Highway/Street: Olive Branch Ct Latitude: 35.5233 Longitude: -78.4064 3. Approximate date land-disturbing activity will commence: September 2023 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.5 acres 6. Amount of fee enclosed: $300.00 The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. (Example: an 8.2-acre application fee is$900). 7. Has an erosion and sediment control plan been filed? Yes No Enclosed: X 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name: Scott Lee E-mail Address: lauraascottleehomes.com Telephone: (919)553-2085 Cell: (919) 369-1937 Fax: (919) 9. Landowner(s) of Record (attach accompanied page to list additional owners): LAST Investments, LLC (919) 553 2085 Name Telephone Fax 104 State Avenue, Suite 103 104 State Avenue, Suite 103 Current Mailing Address current street Address Clayton NC 27520 Clayton NC 27520 City State Zip City State Zip 10. Deed Book No.: 6011 Page No.: 326—328 Provide a copy of the most current deed. Part B. 1. Company (ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a comprehensive list of all responsible parties on an attached sheet). If the company or firm is a sole proprietorship the name of the owner or manager may be listed as the financially responsible parry. Scott Lee Homes, Inc. laurascottleehomes.com Name E-mail Address 104 State Avenue, Suite 103 104 State Avenue. Suite 103 Current Mailing Address Current Street Address Clayton NC 27520 Clayton NC 27520 City State Zip City State Zip Telephone: (919) 553-2085 Fax (919) 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: Laura S. Lee laura&,,scottleehomes.com Name of Registered Agent E-mail Address 104 State Avenue, Suite 103 104 State Avenue, Suite 103 Current Mailing Address Current Street Address Clayton NC 27520 Clayton NC 27520 City State Zip City State Zip Telephone (919)553 2085 Fax Number (919) 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. P. Scott Lee President, Scott Lee Homes, Inc. Type or print name Title or Authority Sig attire Date i, `r^y LA O..TtAt Y VI" , a Notary Public of the County of • SC.d 1 State of North▪ Carolina, hereby certify that uce appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. t t } Witness my hand and notarial seal, this I T day of DOA Lt , 2023 alll p9znts ll l mrtergtp' , • a1',i'•°'Vy�yt°; Notary 's. ). e 9 a°' seal � '1,10= r` P a g m CAMy commission expires t r ,. °,,,,Ncle •••••D•etotlftl'�Hta90,,'