NCC215930_FRO Submitted_20211026

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 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 NIA in the blank.)
Part A.
1. Project Name Papillon Ph2 Lot 8
2. Location of land -disturbing activity: CountyWake City or Township Raleigh
Highway/Street Duskywing Latitude 35.963830 Longitude-78.713800
3. Approximate date land -disturbing activity will commence: 11/30/21
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): • 45
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 Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Nick Brett E-mail Address [e-mail]
Telephone [phone] Cell # 919-609-4344 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Holden Barnett Properties, LLC 919-341-2828
Name Telephone Fax Number
7610 Falls of Neuse, Suite 150 SAME as MAI1I`1-3
Current Mailing Address Current Street Address
Raleigh, NC 27615
City State Zip City State Zip
10. Deed Book No. 17192 Page No.1628 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.
Holden Barnett Properties LLC [e-mail]
Name E-mail Address
7610 Falls of Neuse, Suite 150 Same as mai_ing
Current Mailing Address Current Street Address
Raleigh, NC 27615
City State Zip City State Zip

Telephone
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 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
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
,corr cted informat' should there be any change in the information provided herein.
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Signature Date
V-41Z UAS a Notary Public he County of wat1Q.
State of North Carolina, hereby certify that +) appeared
personally before me this day and being duly sworn acknowleblged that the above form was executed
by him.
Witness my hand and notarial seal, this
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NOTARY PUBW
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