NCC222332_FRO Submitted_20220714

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.
1. Project Name Bryson's Ridge Subdivision
2. Location of land -disturbing activity: County Nash City or Township Spring Hope
Highway/Street NC-581 Latitude 35.956346 Longitude -78.107521
3. Approximate date land -disturbing activity will commence: Spring 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):19.93
6. Amount of fee enclosed: $ 2,000 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Varnell E-mail Address [e-mail]
Telephone[phone] Cell #(252)-382-0012 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Axiom Development, LLC 919-760-0101 N/A
Name Telephone Fax Number
3739 National Drive, Suite 105 3739 National Drive, Suite 105
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
10. Deed Book No. 3154 Page No. 174 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.
Axiom Development, LLC [e-mail]
Name E-mail Address
3739 National Drive, Suite 105 3739 National Drive, Suite 105
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip

Telephone [phone]
Fax Number N/A
(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 Addr ss"
�Ll' -J6006d ACIC
Current Mailing Address
7 e hoke A( 22i�­v
City State Zip
Telephone qlq % 6 0 a1 U ( -
Current Street Address
City
Fax Number
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 a)nd street add/r_ess of the Registered Agent: 1
Name of Registered Agent E-mail Address
lye, { Id V
Current Mailing Address Current Street Address
City State Zip
Telephone /f`% f�� C) L ( 6 t.
City
Fax Number.
State Zip
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.
Ty ep or print name
Signature
Title or Authority
2 r7�2Z
Date
I -S kl(; jAd g _,a Notary Public of the County of
State of North Carolina, hereby certify that --Mi 0,M tX S W � � +4 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
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Notary
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