NCC216531_FRO Submitted_20211122

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 N/A in the blank.)
Part A. Ascend Leadership Academy Expansion - Phase 2
1. Project Name
2. Location of land -disturbing activity: County _Lee City or Township Sanford$ NC
Harvey Faulk Rd Latitude 35.4346 id-7199.1263
Highway/Streete Longitude -
3. Approximate date land -disturbing activity will commence: October 4, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas), 3.0
6. Amount of fee enclosed: $ 945 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Steve Hubrich E-mail Address [e-mail]
1N/A
Telephone Cell # 0"9-471-2895 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Schoolhouse Sanford LLC N/A N/A
Name Telephone Fax -Number
3115 E Lion Lane Ste 300 N/A
Current Mailing Address Current Street Address
Salt Lake City UT 84121 N/A
City State zip City State Zip
10. Deed Book No. 1497 Page No. 202 Provide a copy of the most current deed.
Part B.
I 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):
Hubrich Contracting Inc. [e-mail]
Name E-mail Address
4321 Medical Park Drive Suite 100
Current Mailing Address
Durham NC 2"04
City State Zip
Telephone [phone]
same
Current Street Address
same
City State Zip
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 E-mail Address
Current Mailing Address Current Street Address
same
City State Zip City State Zip
Telephone 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
Telephone
State Zip City
Fax Number
State Zip
(c) in order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Civil Consultants, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
William Akin, PE 919-490-1645
Individual contact person (type or print) 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.
Steve Hubrich
Type or print
Signature
President
Title or Authority
9-27-2021
Date
I, ),/nd 4, Al ez J ) Ca1-t a Notary
yPublic of the County of _DK rh�C M_'
State of North Carolina, hereby certify that S�eUe /T�CbrlCA 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 7
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Seal s ;, ,OTAR �.
day of 5 er 20 a /
Notary
My commission expires 0_ a_