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HomeMy WebLinkAboutNCC240797_FRO Submitted (2)_20240320 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 Chick-fil-A #0766 New Bern 2. Location of land-disturbing activity: County Craven City or Township City of New Bern Highway/Street M L King Jr. Blvd. Latitude 35.103420 Longitude-77.087450 3. Approximate date land-disturbing activity will commence: estimated 6.01.2024 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commerical 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.46 acres 6. Amount of fee enclosed: $200.00 . The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac= $900.00). 7. Has an erosion and sediment control plan been filed? Yes X No Enclosed 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Kimberly Johnson E-mail Address kimberly.johnson@cfacorp.com Telephone 678-836-8524 Cell# Fax# 9. Landowner(s) of Record (attach accompanied page to list additional owners): HS New Bern Outparcels LLC Name Telephone Fax Number 1190 Interstate Parkway Current Mailing Address Current Street Address Augusta GA 30909 City State Zip City State Zip 10. Deed Book No. Page No. 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 party. Kimberly Johnson - Vice President Kimberly.Johnson@cfacorp.com Name E-mail Address 5200 Buffington Road Current Mailing Address Current Street Address Atlanta, GA 30349 City State Zip City State Zip Telephone 678-836-8524 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: C T Corporation System corporationteam@wolterskluwer.com Name of Registered Agent E-mail Address 160 Mine Lake Ct, Suite 200 160 Mine Lake Ct, Suite 200 Current Mailing Address Current Street Address Raleigh, NC 27615-6417 Raleigh,NC 27615-6417 City State Zip City State Zip Telephone Raleigh, NC 27615-6417 Fax Number N/A 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. Kimberly Johnson Vice President Type qr pri'ht name Title or Authority .-k---- _ . ..., Signature'; L-J( J Date -' I, K.1YY rt l.(_ n, O ( , a Notary Public of the County of Ci'Y'a I Ce-e State of G� ' a, hereby certify that V J Uotr �()\'1V\S 0 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 )-I day of i- , 20 023 .. 6ERLY ,i C' A, 4Y-•••:1; .°0 ', PA/WO-PA-8. ;�GNOV ER 9 = EMe ; Notary Seal 2o26 (7 My commission expires Ni bVe.Ar 'mil I, 20` 1(' '2 . zr 0 ere 'Al qAY QV6`s•N% ''`'I►��IJ$% S'