NCC222345_FRO Submitted_20220628

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. FRIENDSHIP DEVELOPMENT OFFSITE UTILITIES
1. Project Name
00
Location of land -disturbing activity: Count Wake
Highway/Street Friendship Rd Latitude 35.670077
3. Approximate date land -disturbing activity will commence-
4.
5.
6.
City or Township Holly Springs
Longitude-78.909750
Spring 2023
Purpose of development (residential, commercial, industrial, institutional, etc.)_ Municipal
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.0
Amount of fee enclosed: $ 500 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00)
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
E-mail Address
Telephone Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Helix Ventures LLC
Name
Telephone Fax Number
3717 National Drive, Ste 209
3717 National Drive, Ste 209
Current Mailing Address
Current Street Address
Raleigh NC 27612
Raleigh NC 27612
City State Zip
City State Zip
18599 404
10. Deed Book No. Page No.
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 res onsible party.
Name
E it Address
3�AeD.
Current Mailing Address
Current Street Address
City Zip
City State Zip
q Q /State �J�, t�
Telephone et to( {t� teZDO
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:
N/A
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:
N/A
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.
Type or int Title or Auth /
a e Date
I �G11`L1111�1 i U V a Notary Public of the County of \NQ) ,
State of North Carolina, hereby certify that }L'0\1V \M VCK1( 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 day of �11�Y11 20 IT
_TA� ;C) Notary
7d= My commission expires
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