NCC217174_FRO Submitted_20220103

FINANCIAL RESPONSIBILITYJOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Littleton Acade
2. Location of land -disturbing activity: County Hallifax
City or Township Littleton
Highway/Street Mosby Avenue Latitude 36.425074 Longitude -77.912967
3. Approximate date land -disturbing activity will commence: 12-15-2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.62
6. Amount of fee enclosed: $ 1,967.00 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next 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 $2,900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
S. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Phillip Ratley
Telephone [phone] Cell #
E-mail Address [e-mail]
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ed Fitts Charitable Foundation
Name
90 Lighthouse Drive
Current Mailing Address
610-322-8145
Telephone
Current Street Address
Fax Number
Jupiter, FL 33469
City State Zip City State Zip
10, Deed Book No. 1056 Page No, 0737 Provide a copy of the most current deed.
2600 696
Part B. 2619
3
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 sate
proprietorship, the name of the owner or manager may be listed as the financially responsible party.
Sela Building Corporation
Name
_8601 Six Forks Road, #400
Current Mailing Address
Raleigh, NC 27615
[e-mail]
E-mail Address
Current Street Address
City State Zip City
State
Zip

Telephone [phone]
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:
Phillip Ratley
Name of Registered Agent E-mail Address
PO Box 468
Current Mailing Address Current Street Address
Elkin NC 28621
City State Zip City State Zip
Telephone [phone] Fax Number
(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:
Triad Design Group, PC [e-mail]
Engineering firm or other consultant E-mail Address
Matt Johnson, PE 336-218-8282
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.
Type or Orint name Title or Authority
/Z- B-7pLi
Signature Date
I, E [ Ice 1 M - El 1P k— a Notary Public of the County of X
State of North Carolina, hereby certify that { T I(l 1f? leaf appeared personally
before me this day and being duly sworn awfedge that the above form was executed by him.
Witness my hand and notarial seal, this day of 0 1f
Ettrra M ti_LeP Notary
"Sly Pubhc, North Carohr <,
Haiilat r,,,urJry
qW M.f f„ „ My commission expires ��
_ TT ,

December 8, 2021
Mr. Dylan Reinhardt
NC DENR
3800 Barrett Drive
Raleigh, North Carolina 27609
Dear Mr Reinhardt:
This letter shall serve as written permission for Sela Building Corporation to
submit an erosion and sedimentation control plan and conduct land disturbing
activity for the Littleton Academy project in Littleton, NC on property owned by Ed
Fitts Foundation. The property is identified as Parcel ID 070098 and is recorded
in Deed Book 2619, Page 335, Parcel ID 0703858 recorded in Deed Book 2600,
Page 696 of the Halifax County Registry and Parcel 3927050339 Recorded in
Deed Book 1056 Page 737 . If you have any questions, please contact us.
Sincereiy,
Edward P. Fitts
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