NCC220785_FRO Submitted_20220224

FINANCIAL RESPONSIBILITY/OWNERSHIP 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: Clyde Commons
2. Location of land -disturbing activity: County Cumberland
Highway/Street Clyde St. & Johnson St. Latitude 35.096281
City or Township Fayetteville
Longitude-78.947727
3. Approximate date land -disturbing activity will commence: 911/21
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7
6. Amount of fee enclosed: $ 445.00 } 1,750.00 . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 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 $2,585).
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 Kevin Lindsa E-mail Address _kevinlindsay@Grawforddsn.c❑rn
Telephone [phone] Cell # 910-920-7661 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Sunrise Real Estate Dev. Group, Inc.
516-306-3959 None
Name
Telephone Fax Number
1586 Hawthorn St.
Same
Current Mailing Address
Current Street Address
Baldwin NY 11510
City State Zip
City State Zip
10, Deed Book No. 10943 Page No.
0749 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) It the company or firm is a sole
proprietorship, the name of the owner or manager may be listed as the financially responsible party.
Sunrise Real Estate rev. Group, Inc.
[e-mail]
Name (Engjellus Papajorgji)
E-mail Address
1586 Hawthorn St.
Same
Current Mailing Address
Current Street Address
Baldwin NY 11510
City State Zip
City State Zip
Telephone [phone]
Fax Number None

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:
CT Corporation System SOS f PA 003 LAB-76
Name (Reference ID# I'z %2m 559 }
160 Mine bake Court, Suite 200
Current Mailing Address
Raleigh, NC 27615
City State Zip
Telephone &1-7 — LA ►o-7 — 3 S __ 5
E-mail Address
Current Street Address
City State Zip
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
Current Mailing Address
City State
Telephone
Zip
E-mail Address
Current Street Address
City State
Fax Number
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:
Crawford Design Company
Engineering Firm or other consultant
Kevin Lindsay, PE
Individual contact person (type or print)
[e-mail]
E-mail Address
910-725-1107
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 attom ey-i n-
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). f agree to provide corrected information should there be
any change in the information provided herein.
Engjellus Pa ajar "i
Type or.,print n�a `
Sign re
Secretary/Treasurer
Title or Authority
Date
I, CQ I "A M V9? 711� iA , a Notary Public of the County of
State of North Carolina, hereby certify that �ti�h� u a i5 1�r'�'fl��� 1��1�] appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this ?4�' day ❑
GIN M VI=RTON
Notary Pubbc, North Carolina
Doke County
MY Commi ion Expires
fy i W+ s Raj , 202 9-
Notary
My commission expires k C> W �"b - -2-naz�-A