NCC216146_FRO Submitted_20211115

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 N/A in the blank.)
Part A.
1. Project Name HAL Properties Hospitality Building
2. Location of land -disturbing activity: County_Caswell City or Township Providence_
Highway/Street_HOM-A-GEN LN_ Latitude_36.5295 Longitude_-79.4213
3. Approximate date land -disturbing activity will commence: November 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial_
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.00 acres
6. Amount of fee enclosed: $ 1260.00 The Express Permitting application fee is a dual charge. The normal fee of
$65.00 per acre is assessed without a ceiling amount. In addition, the Express Permitting supplement is $250.00
per acre up to eight acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9
acres total is $2,585). NOTE: Both fees are rounded up to the next whole acre and need to be paid by separate
checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X_
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name —Jacob Lyle E-mail Address [e-mail]
Telephone [phone] Cell # Same Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
HAL Properties, LLC
Name
15121 Washington Way
Current Mailing Address
Telephone
_Same
Current Street Address
_Bristol Virginia 24202
City State Zip
City
10. Deed Book No. 622 Page No._285 Provide a copy of the most current deed.
Part B.
State
Fax Number
Zip
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.
_ HAL Properties Caswell, LLC cgaMhalpropertiesllc.com
Name E-mail Address
_15121 Washington Way
Current Mailing Address
_ Same
Current Street Address
_Bristol Virginia 24202
City State Zip City State Zip
Telephone_423 534-2411 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:
_Brian M. Ferrell
Name
_4011 University Drive, Suite 300
Current Mailing Address
_Durham NC 27707
City State Zip
Telephone_919 490-0500
[e-mail]
E-mail Address
_Same
Current Street Address
City State Zip
Fax Number 919 490-0873
(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:
_NIA
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone _ Fax Number
E-mail Address
Current Street Address
City State Zip
(c) In 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:
_CE Group, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
_Mark P. Ashness 919 367-8790 x 101 _NIA
Individual Contact Person (type or print) 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.
M1 C.i-,Q"_l J. - MnN
Type or print name Title or Authority
Signature lop,^� Date
I, TrjSlm �/ , V05d N`d , a Notary Public of the County of G N,!� 1yA-
State of v1 In itaa, hereby certify that -� ae! i Cn appeared
�,� c o u
personally befor me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this IrrA
.au Tristan N. Woodard I
Commonwealth of Virginia
Notary Public
Commission No. 790 219
My Commission Expires
day of 069kft 20
J , /w V/v
Notary
My commission expires