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HomeMy WebLinkAboutNCC240173_FRO Submitted_20240118 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION 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 address or phone number is unavailable, place N/A in the blank.) Part A. 1. Project Name Black Creek-Wilson 115kV East-Raise Line and Install 2. Location of land-disturbing activity: County Wilson City or Township Black Creek Highway/Street Old Stantonsburg Rd 35.655198 degrees) 35.655198 -77.893618 Longltude(decimai degrees)• 3. Approximate date land-disturbing activity will commence:January 2024 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Energy Infrastructure 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.60 acres 6. Amount of fee enclosed $2,800 . The Express Permitting application fee is a dual charge. The normal fee of$100.00 per acre(rounded up to the next acre) is assessed without a ceiling amount. In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express Permitting supplemental fee is a fixed$2,000.00 (Example:8.10-acre application fee is$2,900). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed 0 No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Laura Kirby E-mail Address Laura.Kirby@Duke-Energy.com Mobile# 276.613.3776 Phone: office# N/A 9. Landowner(s) of Record (attach accompanied page to list additional owners): Utility Easement (DEP) N/A N/A Name Phone: Office# Mobile# N/A N/A Current Mailing Address Current Street Address N/A N/A City State Zip City State Zip 10. Deed Book No. N/A Page No. N/A 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 listed as the financially responsible party(ies). Duke Energy Progress, LLC Laura.Kirby@duke-energy.com Company Name E-mail Address 410 South Wilmington Street 410 South Wilmington Street Current Mailing Address Current Street Address Raleigh, NC 27601 Raleigh, NC 27601 City State Zip City State Zip Phone: Office# Mobile# 276.613.3776 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: CT Corporation (Karen Rozar) ct-statecommunications@wolterskluwer.com Name of Registered Agent E-mail Address 160 Mine Lake Court, Suite 200 160 Mine Lake Court, Suite 200 Current Mailing Address Current Street Address Raleigh, NC 27615-6417 Raleigh, NC 27615-6417 City State Zip City State Zip Phone: Office#919-844-8360 Mobile# N/A Karen Rozar 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. N/A 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: Dewberry Engineers Inc. ADahlman@Dewberry.com Engineering firm or other consultant E-mail Address Andrew Dahlman 804.767.4712 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. Laura Kirby Sr. Transmission Permitting Manager Type or print name Title or Authority 1/10/24 Cat°K;ielb( Signature Date I, Sabri nra, t. Vat( , a Notary Public of the County of -Percale CtUVI9 State of North Carolina, hereby certify that Laura' r to N 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 V day of Jan 0,�(,� , 20 l • 4&61,0„.„ y. iyoorte ary • 3 0 CON it (1.562). -i L , '‘';Ps ,P My commission expires r-+ f to I co ' "s 6 ; -0 • 6'4411/111111111tttt