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HomeMy WebLinkAboutNCC240045_FRO Submitted_20240111 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. Pinewood 1. Project Name 2. Location of land-disturbing activity: County Brunswick City or Township Leland Highway/Street S.R. 1412 Latitude Longitude 3. Approximate date land-disturbing activity will commence:10-15-21 4. Purpose of development (residential, commercial, industrial, institutional, etc.):residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 127.20 6. Amount of fee enclosed: $8,320.00 . The application fee of$65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$585). 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 E-mail Address Telephone Cell# Fax# 9. Landowner(s) of Record (attach accompanied page to list additional owners): Stanley martin Homes, LLC 980-293-2684 Name Telephone Fax Number 11710 Plaza American Dr#1100 11710 Plaza American Dr. #1100 Current Mailing Address Current Street Address Reston, Va. 20190 Reston, Va. 20190 City State Zip City State Zip 10. Deed Book No.4672 Page No. 1059 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 respon.444isible party. L Name E-mail Address l33tp So ioce)4 . 13;(0 ✓(t,,7,06e. Current Mailing Address Current Street Address CioVitt4.04e. LJL 2sz 73 City State Zip City State Zip Telephone 9 o-243-2&8`T Fax Number 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 • - - -d information should there be any change i 'nformation provided herein. Pp 1444 Typ- • - Title o Authority 9/3°/i/ ignature Date I, VI,im a '62/( , a Notary Public of the County of 4(lke',Lt h0v.6.14q State of North Carolina, hereby certify that 12-0'o& £-eAM\& 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 2- day of (J '1[.1- , 20 r3� ♦�� ,01,1 Notary Sear ,, J. ° a !Ay Commission Expires 7. ^ f% = i My commission expires June 10,2024 °.. 1 G % y♦ • tie " )Li Yi ydA�.E?f \✓ it tttl\