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Part B. <br /> <br />1. Company(ies) who are financially responsible for the land-disturbing activity (Provide a comprehensive list <br />of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is <br />an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies). <br /> <br /> <br />____________________________________ ___________________________________________ <br />Company Name E-mail Address <br /> <br />____________________________________ ___________________________________________ <br />Current Mailing Address Current Street Address <br /> <br />____________________________________ ___________________________________________ <br />City State Zip City State Zip <br /> <br />Phone: Office # _______________________ Mobile #_____________________________________ <br /> <br /> <br />Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form <br />the landowner’s signed and dated written consent for the applicant to submit a draft erosion and sedimentation <br />control plan and to conduct the anticipated land disturbing activity. <br /> <br />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: <br /> <br /> <br />_____________________________________ ___________________________________________ <br />Name of Registered Agent E-mail Address <br /> <br />_____________________________________ ___________________________________________ <br />Current Mailing Address Current Street Address <br /> <br />_____________________________________ ___________________________________________ <br />City State Zip City State Zip <br /> <br /> <br />Phone: Office # ________________________ Mobile #_____________________________________ <br /> <br />______________________________________ <br />Name of Individual to Contact (if Registered Agent is a company) <br /> <br /> <br />(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address <br />of the designated North Carolina agent who is registered on the NC Secretary of State business registry: <br /> <br /> <br />_____________________________________ ___________________________________________ <br />Name of Registered Agent E-mail Address <br /> <br />_____________________________________ ___________________________________________ <br />Current Mailing Address Current Street Address <br /> <br />_____________________________________ ___________________________________________ <br />City State Zip City State Zip <br /> <br /> <br />Phone: Office # ________________________ Mobile #____________________________________ <br /> <br />______________________________________ <br />Name of Individual to Contact (if Registered Agent is a company) <br /> <br />COUNTY OF ORANGE BHAMMERSLEY@ORANGECOUNTYNC.GOV <br />PO BOX 8181 300 W. TRYON STREET <br />HILLSBOROUGH, NC 27278 HILLSBOROUGH, NC 27278 <br />919-245-2300 <br />DocuSign Envelope ID: A6ECD43A-4359-4D26-A9B6-DA39647F9A40