NCC221123_FRO Submitted_20220323

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 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. Pallini Place Subdivision
1. Project Name
2. Location of land -disturbing activity: CountyAlamance City or Township2ssipee
Highway/Street Shepherd Road Latitude36.170554 Longitude-79•519628
3. Approximate date land -disturbing activity will commence: Upon Permitting
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential Subdivision
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16.33 Acres
6. Amount of fee enclosed: $ 1 ,700.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Anthony Hezar E-mail Address [e-mail]
Telephone [phone] cell # 336-260-4910 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Harper Blake Holdings, LLC 336-260-4910 n/a
Name Telephone Fax Number
2601 Northstream Court 2601 Northstream Court
Current Mailing Address Current Street Address
Haw River, NC 27258 Haw River, NC 27258
City State Zip City State Zip
10. Deed Book No. 4188 Page No. 484 Provide a copy of the most current deed.
Part B. 4188 487
4246 367
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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Harper Blake Holdings, LLC [e-mail]
Name E-mail Address
2601 Northstream Court 2601 Northstream Court
Current Mailing Address Current Street Address
Haw River, NC 27258 Haw River, NC 27258
City State Zip City State Zip
Telephone [phone] Fax Number n/a

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:
n/a
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:
n/a
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.
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Typeor print nam Title or Authority
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Signature I Date
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I, JklLid %t a Notary Public of the County of Wli' &
State of North Carolina, hereby certify that �,'�//t.'. Ano appeared
personally before me this day and being duly sulorn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this /' 41
JAN�T A BARKER
ARY PUBLIC
AL.AMANCE COUNTY
North Carolina
My. C«nmission expiresFebruary 7, 2023
day of le li,ti 20
No ry
My commission expires ./�.���