NCC222676_FRO Submitted_20220725

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name 2895 Christian Chapel Church Road
2. Location of land -disturbing activity: County
Christian Chapel
Chatham City or Township New Hill
Highway/Street Church Road Latitude(decimal degrees) 3 5.60 60 Longltude(decimal degrees) -78.9880
3. Approximate date land -disturbing activity will commence: 08/08/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential Single Dwelling
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
2.54
6. Amount of fee enclosed 300 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes IN Enclosed IN No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Terrance Beatty of Carolina Remodeling E-mail Address CRCUniimitedGCQgmail.com
9--Construction LLC
Phone: Office # _pLA Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
C&M Properties of Fuquay — Varina NA
Name
231 Ballard Rd.
Current Mailing Address
Fuquay NC 27526
City State Zip
Phone: Office #
231 Ballard Rd.
Current Street Address
Fuquay
City
NC
State
[phone]
Mobile #
27526
10. Deed Book No. 2165 Page No. 402 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be fisted as the financially responsible party(ies).
Carolina Remodeling & Construction LLC [e-mail]
Company Name E-mail Address
811 Garden St. 811 Garden St.
Current Mailing Address Current Street Address
Lillington NC 27646 Lillington NC 2754E
City State Zip City State Zip
Phone: Office # [phone] Mobile # [phone]
Note: if the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Carolina Remodeling & Construction LLC CRCUn€[e-mail]
Name of Registered Agent E-mail Address
811 Garden St. 811 Garden St.
Current Mailing Address Current Street Address
Lillington NC 27645 Lillington NC 27546
City State Zip City State Zip
Phone: Office # [phone] Mobile # [phone]
Terrance A Beatty (President)
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
NA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of individual to Contact (if Registered Agent is a company)

(c) if the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
NA
Company DBA Name
(d) if order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
MacConnell & Associates, PC
Engineering firm or other consultant
David Barcal
Individual contact person (type or print)
[e-mail]
E-mail Address
[phone]
Phone: Office #
[phone]
Mobile #
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 individuals}
or his attomey-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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Terrance A, Beatty President
Type or print name
Signature
Title or Authority
7/22/2022
Date
1, 4 (x-kVV_.v lI A, lz , a Notary Public of the County of -�
State of North Carolina, hereby certify that _TZ Y1r6'.L-Lc-k. sA.(Q-1-v f3 appeared personally
before me this day and being duly sworn acknowledged that the above form wA executed by himlher.
Witness my hand and notarial seal, this w day of , 20 a^d
f
Ndtory
My commission expires
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