NCC233261_FRO Submitted_20231103

Addendum to FR/O form Part A, Item 9: Landowner of Record Letter of Consent
Landowner of Record Name: 1715 Carthage Street LLC
Property Tax ID#/PIN: 9641-09-5617-00
Property Address Line 1: 105 Weston Estates Way
Property Address Line 2:
City/State/Zip Code: Cary NC 27513
Applicant submitting plan - must match the financially responsible party named in Part B
Section 1 of the Financial Responsibility/Ownership (FR/0) Form: Pulte Home Company LLC
Statement of Landowner Consent: In accordance with NCGS 113A-54.1(a), I hereby declare
that I am the owner or legally authorized representative of the owner of the property described
above and provide my consent for the applicant cited above and in Part B of the FR/0 form to
submit a draft erosion control plan to the State of North Carolina and to conduct the planned
land-disturbing activities on the property listed above and in Part A of the FR/O form.
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Type or Print Nafne Title or Authority
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Signature Date
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Email Telephone

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Westford
"If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Lee City or Township Sanford
1715 Carthage Street 35.45 -79.19
Highway/Street Latitude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: a./0/f ZU Z 3
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 30
6. Amount of fee enclosed: $3,000 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed El No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Chris Raughley E-mail Address [e-mail]
Phone: Office# 919-816-1161 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
1715 Carthage Street LLC , z_
Name Phone: Office# Mobile#
105 Weston Estates Way
Current Mailing Address Current Street Address
Cary NC 27513
City State Zip City State Zip
Page No.716
10. Deed Book No.1678 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 or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Pulte Home Company LLC [e-mail]
Company Name E-mail Address
1225 Crescent Green Dr, Suite 250
Current Mailing Address Current Street Address
Cary, NC 27518
City State Zip City State Lip
Phone: Office#91 8-816-1161 Mobile#
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:
Pulte Home Company LLC [e-mail]
Name of Registered Agent E-mail Address
1225 Crescent Green Dr, Suite 250
Current Mailing Address Current Street Address
Cary, NC 27518
City State Zip City State Zip
Phone: Office# 91 8-816-1161 Mobile#
Chris Raughley
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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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
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 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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Chris Raughley VP Land Development
Type or print name Title or Authority
Signature Date
I, 501-61 "CGt17t1,141 w a Notary Public of the County of "DUYhcty "
State of North Carolina, hereby certify that C)iw'S 12_A appeared personally
before me this day and being duly sworn acknowledged that the abe form was executed by him/her.
Witness my hand and notarial seal, this 14 day of kUat)S} , 20 22
uoiss!wwo•D r,y\ • CGe/&?
iunoo weyma
'Ea1 �11,N H3H1V3-H�'N{VS o ary
My commission expires JUT 21 i 2_O2
SARAH-CATHERINE W BURNS
Notary Public, North Carolina
Durham County My Commission Expires
July 27, 2028

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#