NCC224204_FRO Submitted_20230104

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1
Project Name Palatine Meadows, Lot 2A
2. Location of land -disturbing activity: County Craven
City or Township,
New Bern
Highway/Street 4100 Academic Dr. Latltude(decimaidegrees) 35.096399 Long ltude(decimaidegrees) -77.113333
3. Approximate date land -disturbing activity will commence: November 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential (Multi-fl�„
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.1 ac
6. Amount of fee enclosed $500.00 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Lance D. Paulick E-mail Address [e-mail]1
Phone: Office # 912-210-9992 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Raines Properties, LLC 252-259-2129
Name
312 South Front Street
Current Mailing Address
New Bern NC 28560
City State Zip
10. Deed Book No. 3084 Page No.
Phone: Office # Mobile #
312 South Front Street
Current Street Address
New Bern NC 28560
City
210
State
Zip
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Palatine Meadows Limited Partnership
Company Name
500 South Front Street, 10th Floor
Current Mailing Address
Columbus OH 43215
City State Zip
Phone: office # 614-396-3200
[e-mail]
E-mail Address
500 South Front Street, 10th Floor
Current Street Address
Columbus OH 43215
City State Zip
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
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:
Pease Law PLLC [e-mail]
Name of Registered Agent
16151 Lancaster Highway, Suite B
Current Mailing Address
Charlotte NC 28277
City State Zip
E-mail Address
16151 Lancaster Highway, Suite B
Current Street Address
Charlotte NC 28277
City
State Zip
Phone: office # 704-900-0202 Mobile # [phone]
Paige H. Pease, Esq.
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Pease Law PLLC [e-mail]
Name of Registered Agent E-mail Address
16151 Lancaster Highway, Suite B 16151 Lancaster Highway, Suite B
Current Mailing Address Current Street Address
Charlotte NC 28277 Charlotte NC 28277
City State Zip City State Zip
Phone: office # 704-900-0202 Mobile # [phone]
Paige H. Pease, Esq.
Name of Individual to Contact (if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Baldwin Design Consultants, PA
Engineering firm or other consultant
Igor Palyvoda, PE
Individual contact person (type or print)
[e-mail]
E-mail Address
252-756-1390
Phone: Office #
Mobile #
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(s)
or his attomey-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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Alexander Keller
Type or print name
i nature
VP of Preconstruction
Title or Authority
10/21 /22
Date
lS a Notary Public of the County of F L t
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/her.
Witness my hand and notarial seal, this 2I day of _v & l _� WY , 20_ 1:��
EMILY PHILLIPS
��
d Notary Public
> -C,State of Ohio Nota
My Comm. Expires
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October 3, 2027
My commission expires