NCC220616_FRO Submitted_20220209

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 Environment and Natural Resources. (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.
Project Name Partridge Village Subdivision
2. Location of land -disturbing activity: County_ Harnett _City or Township_Black River Neills Creek
Highway/Street 4391 NC Hwy 210 Latitude N35.457121 Longitude W-78.791691
3. Approximate date land -disturbing activity will commence: Ja nuary 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residen
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 63.2
6. Amount of fee enclosed: $ 4,160 T. 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 Y No Enclosed__
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jack Adcock E-mail Address Jack.Adcock(a Reliabuilt.biz
Telephone [phone] Cell # 919-398-1098 Fax # N/A
Landowner(s) of Record (attach accompanied page to list additional owners):
Harnett Central Holdings, LLC 919-239-4747 N/A
Name Telephone Fax Number
10305 Penny Road 1611Jones Franklin Road Suite 101
Current Mailing Address Current Street Address
Raleigh NC 27606 Raleigh NC 27606
City State Zip City State Zip
10, Deed Book No. 3734 Page No. 0952 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Pennv Road Developers. LLC
Name
10305 Penny Road
Current Mailing Address
Raleigh NC 27606
City State Zip
Telephone [phone]
Jennifer. Erwin a Reliabuilt.biz and
Accountinq_(a-Reliabuilt.Biz
E-mail Address
_1611 Jones Franklin Road Suite 101
Current Street Address
Raleigh NC 27606
City State Zip
Fax Number N/A

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
N/A
Current Mailing Address
N/A
City
Telephone N/A
N/A N/A
State Zip
N/A
E-mail Address
N/A
Current Street Address
N/A
City
Fax Number N/A
N/A
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:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City State Zip
Telephone N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
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.
&1040 L_ �p,��( rs3,c� N4AjA4%&_ Registered Agent for Harnett Central Holdings, LLC
Type or print name Title or Authority
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nature i Date
` , a Notary Wake -
I, J��'►1 �/ Lr��v, (`ry��, Public of the County of
State of North Carolina, hereby certify that fIC%Qr� L-V(1nASSC ,� appeared personally
before me this day and being duly sworn acknowledged that the aboveform- was executed by him.
Witness my hand and notarial seal, this
�'•�;% pTARY �; •3
Z g day of C)2-k)
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Not Ury
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