NCC221338_FRO Submitted_20220407

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. 1005 Dunn Road
1. Project Name
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street Dunn Road Latitude 35.060833 Longitude,78.838888
3. Approximate date land -disturbing activity will commence: Fall 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12
6. Amount of fee enclosed: $ 780.00 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 Maggie Houston, P.E. E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Middle Road Properties
Name Telephone Fax Number
P. O. Box 2507 P. O. Box 2507
Current Mailing Address Current Street Address
Fayetteville, NC 28302 Fayetteville, NC 28302
City State Zip City State Zip
10. Deed Book No. 6297 Page No. 155 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.
HITT Contracting Inc. [e-mail]
Name
6601 Six Forks Rd Suite 330
E-mail Address
6601 Six Forks Rd Suite 330
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State
Telephone [phone]
Zip City State Zip
Fax Number [phone]

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
Fax Number
State Zip
(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
Telephone
State
E-mail Address
Current Street Address
Zip City State Zip
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.
*-,
Vice President
Title or Authority
6.8.201
Date
Jennifer Probasco a Notary Public of the County of Wake
State of North Carolina, hereby certify that Kyle O'Brien 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 8th
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P'�n�`''f.
Notary Public C7
Wake
Seal - County -
My Comm. Exp.
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CAR
day of June
Jennifer Probasco
Notary
202021
My commission expires 06-13-2022