NCC216615_FRO Submitted_20211130

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 erosiod 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 Calyx Senior Living Fuquay-Varina
2.
3.
4.
5.
Location of land -disturbing activity: County Wake
Highway/Street 1121 E. Academy St. Latitude 35.5840
City or Township Fuquay-Varina
Longitude-78.7808
Approximate date land -disturbing activity will commence: December, 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.60 acres
6. Amount of fee enclosed: $ -- 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 x No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kerry Perkins E-mail Address_ [e-mail]
Telephone [phone] Cell # 919-306-3806 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Carillon Assisted Living of Fuquay-Varina 11 LLC 919-852-4000
Name Telephone Fax Number
4901 Waters Edge Drive, Suite 200 4901 Waters Edge Drive, Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27606 Raleigh NC 27606
City State Zip City State Zip
10. Deed Book No. 018567 Page No. 01526 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.
Carillon Assisted Living, LLC [e-mail]
Name E-mail Address
4901 Waters Edge Drive, Suite 200
Current Mailing Address
Raleigh NC 27606
City State Zip
4901 Waters Edge Drive, Suite 200
Current Street Address
Raleigh
City
NC 27606
State
Zip

Telephone [phone] 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
Current Mailing Address
City
Telephone,
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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
Current Mailing Address
City
Telephone.
E-mail Address
Current Street Address
State Zip City State Zip
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
corrected information should there be any change in the information provided herein.
Karen aoriarty
Type o I brint n,
Sign
Manager, Carillon Assisted Living, LLC
Title or Author'ty
c1 �3
Date
a Notary Public of the County of Le,e.
State of North Carolina, hereby certify that a-fr, -o-,4o appeared
personally before me this day and being duly sworn acknowledg that the ab ve form was executed
by him.
Witness my hand and notarial seal, this r40 day of 1VQj%t±}'1 ., 20 c i
MELINDA 6 TAYLOR• /
Notary Public, North Carolina
Lee County ULj��3
My �ommis�snp�res Not
My commission expires Y Y )aV 6, p2L&