NCC216193_FRO Submitted_20211109

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 NIA in the blank.)
Part A.
Project Name: Crabtree Creek West Greenway
2. Location of land -disturbing activity: County Wake City or Township Raleigh
Highway/Street Ebenezer Church Road Latitude 35.84521 Longitude-78.72450
3. Approximate date land -disturbing activity will commence: Aril 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Greenway
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12 acres
6. Amount of fee enclosed: $ 780.00 . 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 X No Enclosedx
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Lisa Schiffbauer E-mail Address_ Lisa. Schiffbauer ct,raleighnc.gov
Telephone [phone] Cell # 919-454-1133 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Raleigh
Name
PO Box 590
Current Mailing Address
Raleigh NC 27602
City State Zip
919-996-4785 919-996-7486
Telephone Fax Number
222 W. Hargett Street
Current Street Address
Raleigh NC 27601
City State Zip
10. Deed Book No.SEE ATTACHED Page No.SEE ATTACHED Provide a copy of the most current deed.
Part B.
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):
City of Raleigh ATTN: PRCR Director Scott. PaVne(d-),raleighnc.goV
Name E-mail Address
PO Box 590 222 W. Har ett Street
Current Mailing Address Current Street Address
Raleigh NC 27602 Raleigh NC 27601
City State Zip City State Zip
Telephone [phone] Fax Number 919-996-7486

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:
NIA
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
corrected information should there be any change in the information provided herein.
Scott Payne _ Interim Parks Recreation & Cultural Resources Director
Type or pri t name Title or Authority
• Lq 1 v5
Sigrfature Date
1, LM, a Notary Public of the County of
State of North Carolina, hereby certify that 5cnL appeared
personally before me this day and being duly sworn acknowl dged that the above form was
executed by him.
Witness my hand
rial seal, this ___1
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