NCC223254_FRO Submitted_20220922

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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. Baker Preserve Subdivision
1. Project Name
2. Location of land -disturbing activity: County Franklin City or Township Louisburg
Highway/Street
US Highway 401 S Latitude 35.98 N Longitude -78.39 W
3. Approximate date land -disturbing activity will commence: September 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.) Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.0 AC
6. Amount of fee enclosed: $ $2,700.00 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a 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 a fixed $2,000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
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:
NameMichael A. Moss E-mail Address [e-mail]
919-556-3148 n/a n/a
Telephone Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Baker Development, LLC n/a n/a
Name Telephone Fax Number
PO BOX 610 n/a
Current Mailing Address Current Street Address
Youngsville NC 27596 n/a n/a n/a
City State Zip City State Zip
10. Deed Book No. 2296 Page No. 692 & 740 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
Baker Development, LLC [e-mail]
Name
PO BOX 610
Current Mailing Address
Youngsville NC 27596
City State
919-556-4700
Telephone
E-mail Address
n/a
Current Street Address
n/a n/a n/a
Zip City
n/a
Fax Number
State
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:
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone.
Fax Number
(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:
FLM Engineering, Inc [e-mail]
Engineering Firm or other consultant E-mail Address
Chase Massey, PE 919-423-8975
Individual contact person (type or print) Telephone
nla
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.
Michael Moss
Type or print name
Signature
Member
Title or Authority
7- zS�ZZ
Date
I, �� (n • 1 I o V_c - , a Notary Public of the County of WC. oc L
State of North Carolina, hereby certify than L� G►��� appeared personally �
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and note
Seal
of , 20,1a
N ary
My commission expires 4 7. LDz