NCC215533_FRO Submitted_20211026

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. Bainbridge Cary
1. Proiect Name
2. Location of land -disturbing activity: County Wake City or Township Cary
Highway/Street NC-54 Latitude35.7982 Longitude-78.7997
3. Approximate date land -disturbing activity will commence:9/27/21
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):15
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? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Alex Barroso E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bainbridge -Gopher Cary Owner LLC [phone]
Name Telephone Fax Number
401 Harrison Oaks Blvd. Suite 250
Current Mailing Address Current Street Address
Cary, NC 27513
City State Zip City State Zip
10. Deed Book No. Page No. 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.
Bainbridge -Gopher Cary Owner LLC [e-mail]
Name E-mail Address
401 Harrison Oaks Blvd. Suite 250
Current Mailing Address Current Street Address
Cary, NC 27513
City State Zip City State Zip
Telephone [phone] Fax Number

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip 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 author yqp execute instruments for the Financially Responsible Person). I agree to provide
corrected Infolmation should there be any change in the information provided herein.
Type or plat name
ature
Nl� -A.T wr%C'SE
Title or Authority
1o�A�2�
Date
I, �'*() j Q. �LI �'C/ , a Notary Public of the County of h►A V �� VV1
State of North Carolina, hereby certify that Alf y (�)nVyOSo 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 A*day of QMbXA/ , 20'7,1_
JODI O. KITE
Notary Public, North Carolina
Durham County NO a
My Commission Expires
e June 26, 2026
My commission expires , jy�V1L Z(o .'Iiy'1i10