NCC232589_FRO Submitted_20230828

.0 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
,? SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity that disturbs one or more acres as covered by the Town of
Clayton Soil Erosion and Sedimentation Control Ordinance before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Clayton. Lots smaller than one
acre that are part of a larger plan of development are also subject to Town of Clayton Soil Erosion and
Sedimentation Control Ordinance and are required to complete this form. (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 NameCalamar Senior Living
2. Location of land-disturbing activity: County JOHNSTON City or Township CLAYTON
Highway/StreetNC HWY 42 Latitude35.631358 Longitude-78.508412
3. Approximate date land-disturbing activity will commence:April 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):7.72
6. Has an erosion and sediment control plan been filed? Yes No Enclosed
7. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Cory Bujnicki E-mail Address [e-mail]
Telephone [phone] Cell# 716-482-5446 Fax# [phone]
8. Landowner(s) of Record (attach accompanied page to list additional owners):
RM82 HOLDINGS, LLC 716-693-0006 716-693-3590
Name Telephone Fax Number
3949 Forest Parkway Ste 100
Current Mailing Address Current Street Address
N Tonawanda NY 14120
City State Zip City State Zip
9. Deed Book No.6441 Page No.521 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.
Calamar Construction North America, LLC [e-mail]
Name E-mail Address
3949 Forest Parkway Ste 100
Current Mailing Address Current Street Address
N Tonawanda NY 14120
City State Zip City State Zip
Telephone [phone] Fax Number 716-693-3590

DocuSign Envelope ID:5BF0632A-CF09-4EFD-9A6B-234F83A3A761
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Corporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Avenue, Suite 550
Current Mailing Address Current Street Address
Raleigh NC 27608
City State Zip City State Zip
Telephone [phone] 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.
Jerald L. Hill President Construction & Dev
flyperaEYnt name Title or Authority
41J. W 6/27/2023
k.s-ovaleht8848B... Date
I, I Jelocc^n.i1 AI n /a_1,1 , a Notary Public of the County of i°"t-€
!get.;, yU i< ,s persc�c_11
State of Net*I-G rrofif, hereby certify that ,1ra(
e (4 L H( I 1 eei- `A
Koc,uy, *c. personally-befefe me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this 7 day of , 20 2 3
31)-40,e!' -h Od'(°c1,-)
Notary
Seal ++
My commission expires -7 l 31 ) a0a6
DI E37RAH NOLAN
Notary Public, Stats of "N. w York
Qualified in E,ie County
My Comrniasion Expires July 31 20 ale
01 NQ4d08013 �