NCC223390_FRO Submitted_20220930

City of Henderson For City Use Only
ate Engineering Department ° From:
Post Office Box 1434 • 900 S. Beckford Dr.
Henderson, NC 27536-1434
Phone: [phone] / Fax: [phone]
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity covered by the Act before this form has been
completed and filed with the appropriate Office of the City of Henderson, Engineering Department,
Attn: Clark Thomas, Director of Engineering. Please make payable the appropriate fee that must
accompany submission of this form to "City of Henderson."
Part A
1. Name of Project: Red Oak Apartments
2. Location of land disturbing activity: Latitude: 36.3386
(Highway/Street/Address) "0" Red Oak Road
3. Approximate date land disturbing activity will commence
4. Purpose of activity (residential, commercial, industrial, etc.):
5. Amount of acreage of land to be disturbed or uncovered
Longitude:-78.4482
May 2022
Residential
7.35 Ac.
Plan Review Fee*
Permit Inspection Fee
0.50 acre to 0.999 acre = $75.00
0.50 acre to 0.999 acre = $125.00
1 to 3 acres = $100.00
1 to 3 acres = $225.00
More than 3 acres = $125.00 + 20.00 per acre
More than 3 acres = $325.00 + 20.00 per acre
6. Amount of fee enclosed (plan review + permit inspection): $ $770.00 ($285.00 + $485.00)
7. Has an Erosion & Sedimentation Control plan been filed? Yes (❑) No (❑) Enclosed (WI)
8. Person to contact or send copy of inspection reports during construction who is responsible for
implementation of measures:
Contact Name: Matt Raab Phone No.:
Email: [e-mail] Cell No.: [phone]
9. Land Owner(s) of Record (use blank pace to list additional owners):
Owner 1
Owner 2
Name
Red Oak Apartments, LLC
Current Mailing Address
6749 Lake Dale Way
Code
Clemmons, NC 27012
_CitylStatelZip
No.
[phone]
-Telephone
Email Address
[e-mail]
10. Indicate County, Book, and Page where deed or instrument is filed and attach a copy of the deed to this
form (use blank page to list additional deeds or instruments):
County Vance County
County
Book 1394
Page 0491
Page
Rev. 08/18

*The application fee for a single family residence with a lot 9 acre or more disturbed is $100.00
Part B
1. Person(s) or Firm(s) financialliv responsible for this land-disturbingactivi
2
Person/Firm
Person/Firm
Name
Red Oak Apartments, LLC
Current Mailing Address
6749 Lake Dale Way
CityLStatelZip Code
Clemmons, NC 27012
Telephone No.
[phone]
Email Address
[e-mail]
Registered Agent, if any, for the person or firm financially responsible:
Name
Current Mailing Address
CitylStatelZip Code
Telephone No.
Email Address
3. The above information is true and correct to the best of my knowledge and belief and was provided by me
while under oath. (This form must be signed by the financially responsible person if an individual and by
an officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the
financially responsible person if not an individual).
Signature
Printed Name Red Oak Apartments, La, by KRP Investments, LLC, Manager
Title or Authority By: Karen R. Perry, Managing Member of KRP Investments, LLC
Date o ZDZZ
I, bAvI s "Y , a Notary Public of the County of P- aWLPH , State of North Carolina,
hereby certify that Karen R. Perry personally before me this day and under oath
acknowledge that the above form was executed by him.
Witness my hand and notarial seal, this 4 day of Ape tz , 20 22-
Notary:
Is
o NOTARY J�
PUBLIC �Q
.y
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Rev. 08118