NCC216571_FRO Submitted_20211124

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 NIA in the blank.)
Part A. Kennebec CrossingSubdivision
1. Project Name
2. Location of land -disturbing activity: County Wake City or Township Angier
Highway/Street Kennebec Church Rd Latitude 35d32'5.65" Longitude 78d45'12.65"
3. Approximate date land -disturbing activity will commence: June 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
Residential Development
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 20
6. Amount of fee enclosed: $ 1,300.00 . 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 Joe Cebina E-mail [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
KCTBM, LLC 919.876.9200
Name
6131 Falls of Neuse Road, Suite #200
Current Mailing Address
Raleigh, NC 27609
Telephone Fax Number
Same as Mailing address.
Current Street Address
City State Zip City State zip
10. Deed Book No. 3977, 18481 Page No 66,2096-2105 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.
Jessica Head/KCTBM, LLC [e-mail]
Name E-mail Address
6131 Falls of Neuse Road, Suite 200 6131 Falls of Neuse Road, Suite 20
Current Mailing Address
Raleigh NC 27609
City State Zip
Telephone [phone]
Current Street Address
Raleigh NC 27609
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
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 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.
Jessica Head
-I kr7 0 �=
Title or Authority
5(1 /2_02-4
Date
I, AYZ) c) 4Q - D.12Az-^7t , a Notary Public of the County of GVA-A-- -,-
State of North Carolina, hereby certify that ;I -,,u 14 r. 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 _LL � day of . rt•t;t-I , 20 1 f
ANN W. THIANI
Notary
seiNOTARY PUBLIC
WAKE COUNTY, N.C. ? My commission expires