NCC215510_FRO Submitted_20211004

NC Dept of Environmental Quality
SEP 10 2:' iJ
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Raleigh Regional Office
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 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 NIA in the blank.)
Part A.
1. Project Name Sutherland Station
2. Location of land -disturbing activity: CountyFranklin City or Township Younasville
Highway/Street Sutherland Drive Latitude 36.080734 N Longitude 78.507577 W
3. Approximate dale land -disturbing activity will commence: Winter 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.23 acres
6. Amount of fee enclosed: $ 975.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Howard Jacobson c/o PEM Entities, LLC E-mail Address [e-mail]
Telephone [phone] Cell # 919 624-2809 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
PEM Entities, LLC NIA NIA
Name Telephone Fax Number
7575 Tarpon Cove Circle 7575 Tarpon Cove Circle
Current Mailing Address Current Street Address
LAKE WORTH FL 33467 LAKE WORTH FL 33467
City State Zip City State Zip
10. Heed Book NO 1851 Page No. 23 Ftovide 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):
Howard Jacobson c/o PEM Entities, LLC [e-mail]
Name E-mail Address
3821 Falls River Avenue 3821 Falls River Avenue
Current Mailing Address Current Street Address
Raleigh NC 27624 Raleigh NC 27624
City State Zip City State Zip
Telephone [phone] Fax Number NIA

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:
NIA
Name
E-mail Address
NIA NIA
Current Mailing Address Current Street Address
NIA NIA
City State Zip City State Zip
Telephone NIA Fax Number NIA
(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:
Ni A NIA
Name of Registered Agent E-mail Address
NIA N/A
Current Mailing Address Current Street Address
NIA NIA
City State Zip City State Zip
Telephone NIA Fax Number NIA
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.
U
ype o ame Title or Authorit
Sig Date
I, 'E3t,� W�Yz:' , a Notary Public of the County of VAKC
State of North Carolina, hereby certify that +�OW 6�r d N\4-n JaCabsdo 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 _QA_day of A %36k , 20--
BURTON BALOUBI Notary
Seallotary Public
Wake Co" North Carolina My commission expires 1 t 4 Z 3
My Commission Expires Nov, 14, 2023