No person may initiate any land-disturbing activity on ½ or more contiguous acres as covered by the soil erosion and sedimentation control ordinance before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Zoning Administrator of the town of Kill Devil Hills. (Please type or print and, if question is not applicable, place N/A in the blank.)
PART A.
1. Project Name
2. Location of land-disturbing activity: and Highway Street
3. Approximate date land-disturbing activity will be commenced:
4. Purpose of development (residential, commercial, industrial and the like):
5. Approximate acreage of land to be disturbed or uncovered:
6. Has an erosion and sedimentation control plan been filed?
Yes No
7. Person to contact should sediment control issues arise during land-disturbing activity:
Name
Telephone
8. Landowner(s) of Record (use blank page to list additional owners): Name(s)
Current Mailing Address Current Street Address
City State Zip City State Zip
9. Recorded in Deed Book No. Page No.
PART B.
1. Person(s) or firm(s) who are financially responsible for this land-disturbing activity (use a blank page to list additional persons or firms):
Name of Person(s) or Firm(s)
Mailing Address Street Address
City State Zip City State Zip
Telephone Telephone
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the North Carolina Registered Agent.
Name
Mailing Address Street Address
City State Zip City State Zip
Telephone Telephone
(b) If the Financially Responsible Party is a Partnership, give the name and street address of each General Partner (use blank sheet to list additional partners). If the Financially Responsible Party is a Corporation, give name and street address of the Registered Agent.
Name
Mailing Address Street Address
City State Zip City State Zip
Telephone Telephone
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 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.
Type or print name Title or Authority
Signature Date
I, , a Notary Public of the County of , State of North Carolina, hereby certify that 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 day of 20 .
SEAL
Notary
My commission expires:
(Am. Ord. 18-4, passed 6-14-21)