NCC216034_FRO Submitted_20211029

FINANCIAL RESPONSIBILITYIOWNERSHIP 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.G. 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 NIA in the blank.)
Part A. Harper's Glen Subdivision
1. Project Name
2. Location of land -disturbing activity: County Wake City or Township Town of Wendell
Highway/Street929 DOJO Drive Latitude Longitude-78 3510
3. Approximate date land -disturbing activity will commence: Nov. 8, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):residential
5. Total acreage disturbed or uncovered (including oft -site borrow and waste areas): 80.70
6. Amount of fee enclosed: $5265 . 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 Walter Viele E-mail Address [e-mail]
Telephone [phone] cell # 919-524-1324 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Exeter Harper's Glen Developers, LLC
919-818-2512 n/a
Name
Telephone Fax Number
1905 Woodstock Rd., #9250
1905 Woodstock Rd., #9250
Current Mailing Address
Current Street Address
Roswell, GA 30075
Roswell, GA 30075
City State Zip
City State Zip
10. heed Book No. 018755 Page No. 00491 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.
Exeter Harper's Glen Developers, LLC
[e-mail]
Name
E-mail Address
1905 Woodstock Rd, Ste. 9250
1905 Woodstock Rd, Ste. 9250
Current Mailing Address
Current Street Address
Roswell, GA 30075
Roswell, GA 30075
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:
Jeffrey R. Smerko [e-mail]
Name
E-mail Address
2815 Exeter Circle
2815 Exeter Circle
Current Mailing Address
Current Street Address
Raleigh, NC 27608
Raleigh, NC 27608
City State Zip
City State Zip
Telephone [phone]
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:
Timothy Kemper
[e-mail]
Name of Registered Agent
E-mail Address
1905 Woodstock Rd, Ste 9250
1905 Woodstock Rd, Ste 9250
Current Mailing Address
Current Street Address
Roswell, GA 30075
Roswell, GA 30075
City State Zip
City State Zip
Telephone [phone] 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.
Jeffrey R. Smerko
Vice President, Harper's Glen Developer, LLC
Type or print name/ Title or Authority
/�. 16
/ a--0
na Date
I, , a Notary Public of the County of 1.Ie,,_3 kkr Q vte-
State of North Carolina, hereby certify that Jeffrey R. Smerko
personally before me this day and being duly sworn acknowledged
executed by him.
appeared
that the above form was
Witness my hand and notarial seal, this J.1 day of , 20-1
-L
Notary
RPM-
KELSEA MEADOWS My commission expires OL2r
Notary Public
North Carolina
New Hanover County