NCC222855_FRO Submitted_20220810

FINANCIAL RESPONSIBILITY/OWNERS HIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
Noperson may initiate any land -disturbing activity onone mmore acres as covered by the Act before this
form and anacceptable erosion and sedimentation control plan have been completed and approved by the
Land Uum|dx 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 orthe e-mail and/or fax
information unavailable, place N/A inthe blank.)
Part A.
1Project Name U-6243 Holly Springs Road Widening, Phase 2
2. Location of land -disturbing activity: County City or Township Holly Springs
Highway/Street Holly Springs Road Latitude ' Longitude
3. Approximate date land -disturbing activity will monnnnonne: February 2021
4. Purpose of development (residential, uonnnnemia[ industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
O. Amount offee enclosed: The Express Permitting application fee iaa
dual charge. The normal fee of$G5.00 per acre (rounded uptnthe next acre) is assessed without
_ ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres,
after which the Express Permitting supplemental fee is m fixed $2.000.00 (Example: S acres total is
$2.585).
7. Has anerosion and sediment control plan been filed? Yes NnEnclosed X____
M. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Address tim.athy(cDhollysprinqsnc. us
Telephone Cell # Fax#
Q. Landovvner(o)ofRecord (attach accompanied page bolist additional :
Town of Holly Springs 919-557-3924 919-567-1472
Name Telephone Fax Number
128 S. Main Street 128 S. Main Street
Current Mailing Address Current Street Address
Holly Springs NC 27540 Holly Springs NC 27540
City State Zip city State Zip
10. Deed Book No. N/A Page No. N/A — Provide a copy of the most current deed.
PartB.
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 mole
proprietorship, the name of the owner or manager may be listed as the financially responsible party.
Town of Holly Springs kendra.parrish(o)hollysprincisnc.us
Name E-mail Address
128 S. Main Street 128 S. Main Street
Current Mailing Address Current Street Address
Holly Springs NC 27540 Holly Springs NC 27540
city State Zip City State Zip
Telephone Fax Number ��552-980

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
E-mail Address
Current Street Address
State Zip City
Telephone 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:
Kendra Parrish
Name of Registered Agent
128 S. Main Street
Current Mailing Address
kendra.parrish(a hollyspringsnc.us
E-mail Address
128 S. Main Street
Current Street Address
Holly Springs NC 27540 Holly Springs NC 27540
City State Zip City State Zip
Telephone [phone] Fax Number 919-552-9881
(c) In 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:
Kimley-Horn and Associates cathy.kennedy(o)kimley-horn.com
Engineering Firm or other consultant E-mail Address
Cathy Kennedy 919-678-4139 919-677-2050
Individual contact person (type or print) 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 c ange in the information provided herein.
r)floja� RnI4 F-ur I IL_ ld
Type or print narr/te, Title or Authority
Sibnature
Dat
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I, h,r a Notary Public of the County of AE-ire_ A--
State of North Carolina, hereby certify that ' 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 jj? day of mac?. Lxo r� 20 -
SHIRLENA R. WHITE Notary
SIOTARY PUBLIC
Harnett County My commission expires _ , 2C"'2_\
North Carolina —r—
My Commission Expires June 5, 2021