NCC233623_FRO Submitted_20231208

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.)
P1.art AProject Name Hidden Lake Lots 174-251
2. Location of land-disturbing activity: County Franklin City or TownshipYoungsviIIe
Forest Bridge RdNalebrook Ct 36.0550 -78.4517
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence:Decemeber 1st, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 15.67 Acres
6. Amount of fee enclosed: $ 1600.00 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
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 Andy Crawford E-mail Address [e-mail]
Telephone [phone] cell# 919-758-8208 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Ange Executives Estates, LLC
Name Telephone Fax Number
PO Box 1801 301 Fayetteville Street, Suite 1900
Current Mailing Address Current Street Address
Raleigh, NC 27602 Raleigh, NC 27601
City State Zip City State Zip
10. Deed Book No. 1915 Page No.454-457 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.
Eastwood Homes of Raleigh, LLC [e-mail]
Name E-mail Address
7101 Creedmoor Road, Suite 115 7101 Creedmoor Road, Suite 115
Current Mailing Address Current Street Address
Raleigh, NC 27613 Raleigh, NC 27613
City State Zip City State Zip
Telephone[phone] Fax Number(919) 647-4183

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
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.
Type or print name Title or Authority
ii/i5/23
Sign 'fe Date
I,PGt"rn6L7t. , a Notary Public of the County of a-k-e---
State of North Carolina, hereby certify that Ai all C,t((Qu��1WG appeared
personally before me this day and being duly worn acknowledged that the above form was
executed by him.
Witness my hand and notacjal, pal, this /3 day of J , 20 c -1
God;
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?, A %`''S ; = Notary
Seal NOTARY
• ptJBLtC V` My commission expires cg,3cSCA.f'1C XO&CP
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