NCC221060_FRO Submitted_20220404

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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. Sunbelt PC1505 - River Bend
1. Project Name
2. Location of land -disturbing activity: County Craven City or Township River Bend
Highway/Street US Hwy 17 S Latitude 35d57.92"N Longitude-77d8'51.25"W
3. Approximate date land -disturbing activity will commence: March 7, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 6.70
6. Amount of fee enclosed: $ $700 +$4,000 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 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 $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
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 -Craig T. Moffat E-mail Address cmoffat@ moffatproperties.com
Telephone [phone] cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Hwy 17 River Bend, LLC [phone]
Name Telephone Fax Number
701 Finger Lakes Drive
Current Mailing Address
Wake Forest NC
City State
10. Deed Book No.
701 Finger Lakes Drive
Current Street Address
27587 Wake Forest
Zip City
Page No.
NC 27587
State
Zip
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.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Hwy 17 River Bend, LLC [e-mail]
Name
701 Finger Lakes Drive
Current Mailing Address
E-mail Address
701 Finger Lakes Drive
Current Street Address
Wake Forest NC 27587 Wake Forest NC 27587
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Engineering Firm or other consultant E-mail Address
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.
Craig T. Moffat Registered Agent
Type or print name Title or Authority
'7Z Z- -Z? -
Signature Date
IUL'
State of North Carolina, hereby certify that
before me this day and being duly sworn ai
Witness mX,08"d1kM4,nc
Notgg�jfubµc
wake County
CAR„O%o S
a Nota Public the County of
`• appeared personally
e tha the ab ve form was executed by him.
seal, this L-"J day of
My commission expires