NCC222279_FRO Submitted_20220622

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 Environment and Natural Resources. (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 Hadleigh at Cedar Creek Subdivision — Phase 2
2. Location of land -disturbing activity: County Franklin City or Township Franklinton
Highway/Street Cedar Creek Road Latitude N36.031230 Longitude W-78.456993
3. Approximate date land -disturbing activity will commence: March 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 29.6
6. Amount of fee enclosed: $ 2,000 & $1,950 . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 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 $2,585). NOTE: Both fees
are rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes Y No Enclosed
E
im
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Drew Kirchner E-mail Address drew.kirchner(cDlgihomes.com
Telephone [phone] Cell # N/A Fax # N/A
Landowner(s) of Record (attach accompanied page to list additional owners):
LGI Homes - NC LLC
Name
1450 Lake Robbins Dr. Ste 430
Current Mailing Address
The Woodlands TX 77380
City State Zip
111-n- c.. g. -TV- 0.
[phone] x2658 N/A
Telephone Fax Number
1450 Lake Robbins Dr. Ste 430
Current Street Address
The Woodlands TX 77380
City State Zip
714 Provide a copy of the most current deed.
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):
LGI Homes - NC LLC
Name
1450 Lake Robbins Dr. Ste 430
Current Mailing Address
The Woodlands TX 77380
City State Zip
[e-mail]
E-mail Address
1450 Lake Robbins Dr. Ste 430
Current Street Address
The Woodlands TX 77380
City State Zip
Telephone (281 } 362-8998 x2658 Fax Number N/A

2. (a) If the Finmndo|k/ Responsible Party is not a resident of North Candina, give name and street address
of the designated North Carolina Agent:
Josh Spiegel
Name
Current Mailing Address
Raleigh NC 27613
City State Zip
josh. spiegela_lgihomes.com
E-mail Address
Current Street Address
Raleigh NC 27613
City State Zip
Telephone [phone] Fax Number N/A
(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 iaa Corpomabon, give name and street address nfthe Registered Agent:
Corporation Service Company N/A
Name ofRegistered Agent E-mail Address
2626 Glenwood Avenue, Ste 550 2626 Glenwood Avenue, Ste 550
Current Mailing Address Current Street Address
Raleigh_ NC 27608 Raleigh NC 27608_
city State Zip Qh/ State Zip
Telephone [phone] Fax Number N/A