NCC222653_FRO Submitted_20220725

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. Cardinal Woods
1. Project Name
2. Location of land -disturbing activity: County Nash City or Township Nashville
Highway/Street Glover Park Memorial Dr. Latitude 35.952733 Longitude-77.958914
3. Approximate date land -disturbing activity will commence: Winter 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 84.68 acres
6. Amount of fee enclosed: $ 5,525.00 . 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:
E-mail Address Name y
Ra mond Rinker [e-mail]
Telephone [phone] Cell # 919-229-3238 Fax # [phone]
a
Landowner(s) of Record (attach accompanied page to list additional owners):
Mayo Farm Holding, LLC 252-567-7791
Name
5028 Wedgewood Drive
N/A
Telephone Fax Number
5028 Wedgewood Drive
Current Mailing Address Current Street Address
Charlotte NC 28210 Charlotte NC 28210
City State Zip City
10. Deed Book No. 2941 Page No. 422-424
State
Zip
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.
Starlight Homes of North Carolina, LLC [e-mail]
Name E-mail Address
4025 Lake Boone Trail, Ste 200 4025 Lake Boone Trail, Ste 200
Current Mailing Address
Raleigh NC
City State
Telephone [phone]
Current Street Address
27607 Raleigh NC
Zip
City State
Fax Number 919-232-5105
27607
Zip

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
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:
N/A
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State 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.
Raymond Rinker
Type or print e
S-------------------------------------------------
i u e
VP of Land Development
Title or Authority
Date /A 00 Z't
a Notary Public of the County of l
State of North Carolina, hereby certify that ALL appeared
personally before me this day and being duly Isworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of U&&k , 24 I'�
MARY HILL HEROLD
NOT YWU6t_IC
WAKE PJNTY, N.C.
My Commission Expires 9-24-2026.
Notary I
My commission ex Tres I I Z 2, p

APPLICATION IDENTIFICATION
riveway �pplication
ate of
:;rmit No.
n„n+„• NASH
loDment Name: CARDINAL WOODS
Route/Road: NC HWY 58
N.C. DEPARTMENT OF TRANSPORTATION
LOCATION OF PROPERTY:
Exact Distance 1020 ❑ Miles N S E W
® Feet ® ❑ ❑ 191
From the Intersection of Route No. NC HWY 58
STREET AND DRIVEWAY ACCESS
and Route No. ESSEX ROAD
PERMIT APPLICATION
Toward SR-1145
Property WIII Be Used For: ® Residential /Subdivision ❑ Commercial ❑ Educational Facilities ❑ TND ❑ Emergency Services ❑ Other
® is ❑ is not within TOWN OF NASHVILLE City. Zoning Area.
AGREEMENT
• I, the undersigned property owner, request access and permission to construct driveway(s) or street(s) on public right-
of-way at the above location.
o I agree to construct and maintain driveway(s) or street entrance(s) in absolute conformance with the current "Policy on
Street and Driveway Access to North Carolina Highways" as adopted by the North Carolina Department of
Transportation.
e I agree that no signs or objects will be placed on or over the public right-of-way other than those approved by NCDOT.
• I agree that the driveway(s) or street(s) will be constructed as shown on the attached plans.
• I agree that that driveway(s) or street(s) as used in this agreement include any approach tapers, storage lanes or
speed change lanes as deemed necessary.
I agree that if any future improvements to the roadway become necessary, the portion of driveway(s) or street(s)
located on public right-of-way will be considered the property of the North Carolina Department of Transportation, and I
will not be entitled to reimbursement or have any claim for present expenditures for driveway or street construction.
• I agree that this permit becomes void if construction of driveway(s) or street(s) is not completed within the time
specified by the "Policy on Street and Driveway Access to North Carolina Highways".
• I agree to pay a $50 construction inspection fee. Make checks payable to NCDOT. This fee will be reimbursed if
application is denied.
• I agree to construct and maintain the driveway(s) or street(s) in a safe manner so as not to interfere with or endanger
the public travel.
e I agree to provide during and following construction proper signs, signal lights, flaggers and other warning devices for
the protection of traffic in conformance with the current "Manual on Uniform Traffic Control Devices for Streets and
Highways" and Amendments or Supplements thereto. Information as to the above rules and regulations may be
obtained from the District Engineer.
o I agree to indemnify and save harmless the North Carolina Department of Transportation from all damages and claims
for damage that may arise by reason of this construction.
e I agree that the North Carolina Department of Transportation will assume no responsibility for any damages that may
be caused to such facilities, within the highway right-of-way limits, in carrying out its construction.
I agree to provide a Performance and Indemnity Bond in the amount specified by the Division of Highways for any
construction proposed on the State Highway system.
• The granting of this permit is subject to the regulatory powers of the NC Department of Transportation as provided by
law and as set forth in the N.C. Policy on Driveways and shall not be construed as a contract access point.
• I agree that the entire cost of constructing and maintaining an approved private street or driveway access connection
and conditions of this permit will be borne by the property owner, the applicant, and their grantees, successors, and
assignees.
• I AGREE TO NOTIFY THE DISTRICT ENGINEER WHEN THE PROPOSED WORK BEGINS AND WHEN IT IS
COMPLETED.
2004-07 NOTE: Submit Four Copies of Application to Local District Engineer, N.C. Department of Transportation TEB 65-04rev.
61-03419

SIGNATURES OF APPLICANT
PROPERTY OWNER (APPLICANT)
COMPANY Starliqht Homes North Carolina, LLC- Ravmond Rinker
SIGNATURE
ADDRESS 4025 Lake Boone Trail. Ste 200 / Raleiah. NC 27607
Phone No. 9192323655
NAME
SIGNATURE
ADDRESS
S
�]
AUTHORIZED AGENT
COMPANY Bateman Civil Survey-Shayne Leathers
SIGNATURE
ADDRESS 2524 Reliance Avenue, Apex NC 27539
Phone No. 9195771080
NAME
SIGNATURE
ADDRESS
WITNESS
Bateman Civil Survey-Shelbey Sparrow
2524 Reliance Avenue, Apex NC 27539
9195771080
APPROVALS
APPLICATION RECEIVED BY DISTRICT ENGINEER
SIGNATURE
DATE
APPLICATION APPROVED BY LOCAL GOVERNMENTAL AUTHORITY (when required)
SIGNATURE
TITLE
DATE
APPLICATION APPROVED BY NCDOT
SIGNATURE
TITLE
DATE
INSPECTION BY NCDOT
SIGNATURE
TITLE
DATE
COMMENTS: