NCC241314_FRO Submitted_20240430

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'VIM T� FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity that disturbs one or more acres as covered by the Town of
Clayton Soil Erosion and Sedimentation Control Ordinance before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Clayton. Lots smaller than one
acre that are part of a larger plan of development are also subject to Town of Clayton Soil Erosion and
Sedimentation Control Ordinance and are required to complete this form. (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 Pecan Lane Lots 1-3
2. Location of land-disturbing activity: County JOHNSTON City or Township CLAYTON
Highway/Street Pecan Lane Latitude 35.64912 Longitude-78.52699
3. Approximate date land-disturbing activity will commence:ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):3.49
6. Has an erosion and sediment control plan been filed? Yes No Enclosed ✓
7. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameMike Nedriga E-mail [e-mail]
Telephone [phone] Cell# 919-779-9664 Fax# N/A
8. Landowner(s)of Record (attach accompanied page to list additional owners):
Capital Properties of North Carolina, LLC 91 9-779-9664 N/A
Name Telephone Fax Number
1540 Grand Willow Way 1540 Grand Willow Way
Current Mailing Address Current Street Address
Raleigh NC 27614 Raleigh NC 27614
City State Zip City State Zip
9. Deed Book No.6489 Page No.942 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.
Capital Properties of North Carolina, LLC [e-mail]
Name E-mail Address
1540 Grand Willow Way 1540 Grand Willow Way
Current Mailing Address Current Street Address
Raleigh NC 27614 Raleigh NC 26714
City State Zip City State Zip
Telephone[phone] Fax Number N/A

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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip
Telephone N/A 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
is a Corporation, give name and street address of the Registered Agent:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip
Telephone N/A 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.
Michael Walter Nedriga Manager
T e or t me - Title or Authority
//' -06 L-7
i nature Da e
Pi\c.v ! Uq i\ , a Notary Public of the County of We.
State of North Carolina, hereby certify that AA`/ I^etc \/`/61/r M4r14, 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 day of ` KiMarl , 20
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SPENCER TURPIN
NOTARY PUBLIC Notary
Seatilake County,North Carolina LQ
My Commission Expires February 23,2028 My commission expires 2�/a G� (�