NCC221422_FRO Submitted_20220421

WAKE COUNTY 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 Wake
WAKECounty Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
. Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name Sanctuary at Yates Mill - Lots 66, 67. 68 & 80
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Sanctuary Woods Ln Latitude 35.71251 Longitude -78.72781
3. Approximate date land -disturbing activity will commence: April• 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential (4 homes)
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 2.06 ac (does not clear repair areas or rear water supply watershed buffers)
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Austin Robertson
Telephone [phone] Cell #
E-mail Address [e-mail]
919-337-5245 Fax # n/a
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Halcyon Homes. LLC 919-337-5245
Name(s)
PO Box 33578
Current Mailing Address
Telephone
4994 Indiana Ave. Ste. A
Current Street Address
arobertson@halcyonhomesnc.
Fax or E-mail address
Raleigh NC 27636 Winston Salem NC 27106
City State Zip City State Zip
8. Deed Book No. 018245 Page No. 01830 Provide a copy of the most current deed.
see attached for all four lots ownership/deeds listed out
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Halcyon Homes, LLC [e-mail]
Name E-mail Address
PO Box 33578
Current Mailing Address
4994 Indiana Ave, Ste. A
Current Street Address
Raleigh NC 27636 Winston Salem NC 27106
City State Zip City State Zip
Telephone [phone] Fax Number n/a

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control. Ordinance and/or Land
Disturbance Permit:
Austin Robertson
Name
PO Box 33567
Current Mailing Address
Raleigh NC 27636
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
5034 Hollyridge Drive
Current Street Address
Ralei
City
Fax Number n/a
NC 27612
State Zip
(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:
James W. Robertson, Jr. [e-mail]
Name of Registered Agent E-mail Address
PO Box 11226 4994 Indiana Ave, Ste. A
Current Mailing Address Current Street Address
Winston Salem NC 27116 Winston Salem NC 27116
City State Zip City State Zip
Telephone [phone] Fax Number n/a
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.
James W Robertson Jr. Manager, Halcyon Homes, LLC
Type or print name Title or Authority
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%1 a Notary Public of the County of A.1A
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State of North Carina, hereby certify that gQ[j'y nail. p,4�� , r-A 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 1_day of
OFFICIAL SEAL (�Notary
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