NCC216143_FRO Submitted_20211108

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. Perimeter's Edge
1. Project Name
2. Location of land -disturbing activity: County Wake City or Township Morrisville
Highway/Street MCCrimmon Latitude 35.8481 Longitude-78.8299
3. Approximate date land -disturbing activity will commence:11 /01 /21
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.76
6. Amount of fee enclosed: $195 . 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 XX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Richard McNeill E-mail Address [e-mail]
Telephone Cell # 9194278713 _ Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Durham Perimeter Park Holdings, LLC 6178335275
Name Telephone Fax Number
260 Franklin Street 260 Franklin Street
Current Mailing Address Current Street Address
Boston MA 02110 Boston MA 02110
City State Zip City State Zip
10. Deed Book No. 017734 Page No. 01545 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.
Durham Perimeter Park Holdings, LLC [e-mail]
Name E-mail Address
260 Franklin Street
Current Mailing Address
Boston MA 02110
City State Zip
Telephone [phone]
260 Franklin Street
Current Street«gddl,s" :r;•,i� F'��
Boston ; .:. M'� 110
_ 5
City : ' State Zip
Fax NumbeF''

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:
Registered Agent Solutions, Inc
Name
E-mail Address
176 Mine Lake Court, Suite 100
176 Mine Lake Court, Suite 100
Current Mailing Address
Current Street Address
Raleigh NC 27615
Raleigh NC 27615
City State Zip
City State Zip
Telephone [phone]
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.
Joe Van Saun Partner
Type or n na
T/
Sign ure
Title or Authority
Date
I, \ fl!fCA, a Notary Public of the County of _ gSv-�11L
sS�chc�e;,
State of , hereby certify that O L y CAr 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 2K day of 20Z1
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