NCC216829_FRO Submitted_20211216

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. 1. Project NameBaker Subdivision
2. Location of land -disturbing activity: County Franklin City or Township Youngsyille
Highway/Street NC Highway 98 Latitude 35058�31.53" Longitude 7802151.60"
3. Approximate date land -disturbing activity will commence: DECEMBER 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4'7.76
53,f 20 - (preNavey paid amount of S2,7M = M
6. Amount of fee enclosed: $ . 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 Mike Jones E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
D.R. Horton - Terramor, LLC 919-241-7444
Name Telephone Fax Number
7208 Falls of Neuse Rd, Suite 201 7208 Falls of Neuse Rd, Suite 201
Current Mailing Address Current Street Address
Raleigh, NC, 27615 Raleigh, NC, 27615
City State Zip City State Zip
10. Deed Book No. 2277 Page No.1876 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.
D.R. Horton - Terramor, LLC Karl. [e-mail]
Name E-mail Address
7208 Falls of Neuse Rd. Suite 201 7208 Falls of Neuse Rd. Suite 201
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State
Telephone [phone]
Zip 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
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 Zip
Telephone
E-mail Address
Current Street Address
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 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.
Karl Beyer Division CFO
Type or pri me
Signatur
Title or Authority
Z — O ec — 2iz, i
Date
I, d .( L�k .4LL, a Notary Public of the County of -S y 1
State of North Carolina, hereby certify that K o_t- Jam. / t t.; e-r appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
of da �� Witness my hand and notarial seal, this y , 20 Z-1
Adrienne Mabry Notary
NOTAfigYBUG
Johnston ounty, NO My commission expires 2--2 , 2- 0 Z 2,
My Commission Expires January 22, 2022