NCC223606_FRO Submitted_20221024

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 Holly Springs Rd Widening
2. Location of land -disturbing activity: County Wake City or Township Holly Springs
Highway/Street Holly Springs Rd Latitude(decimaidegrees) 35.65485 Longitude(decimaidegrees)-78.829139
3. Approximate date land -disturbing activity will commence: Fall 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility Installation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.0
Express:$750
00
6. Amount of fee enclosed Standard:
otaias 050
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, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application feeds $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bob LepsiC E-mail Address [e-mail]
Phone: Office # 919-810-7883 Mobile # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Windward Pointe HOA Inc N/A N/A
Name Phone: Office # Mobile #
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
10. Deed Book No. 006637 page No. 00237 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 listed as the financially responsible party(ies).
Public Service Company of North Carolina, Inc.
[e-mail]
Company Name E-mail Address
P.O. Box 1398 800 Gaston Road, Building A
Current Mailing Address Current Street Address
Gastonia, NC 28053 Gastonia, NC 28056
City State Zip City State Zip
Phone: Office # 704-810-3259 Mobile # N/A
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:
CT Corporation System (NCSOS ID#519077) [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct, Ste 200 160 Mine Lake Ct, Ste 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City
Phone: Office # 302-777-0204
Mobile # N/A
Sherry McGinnes
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address
City State Zip
Phone: Office #
Current Street Address
City State Zip
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.
N/A
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:
Kleinfelder, Inc.
Engineering firm or other consultant
Keely Lane
Individual contact person (type or print)
[e-mail]
E-mail Address
910.233.8858 N/A
Phone: Office # 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 individual(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Andrew Moore Director - Engineering & Construction
Type or print name
61"z
Signature
Title or Auth
V�3;122_
Date
I, %vl 0 , a No Public of the County of &CJt&- n
State of North Carolina, hereby certify that A"J YP- 66 T e appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
rd
Witness my hand and notarial seal, this 2-3 day of 20'Z?-
Eal
HIA M. ALVARADO
OTARY PUBLIC
aston County
orth Carolina
sion Expires
Not y
My commission expires 0CA 1 W —4 ; ���

Continued from Items 9 & 10 in Part A of the Financial ResponsibilitylOwnership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Christopher Rouse
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State
Zip City State Zip
Deed Book No. 015115
Page No. 02152
9
Provide a copy of the most current deed.
Landowner of Record:
Wake County Board of
Education
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Deed Book No. 006306
Pa e No. 00031
g
Provide a copy of the most current deed.
Landowner 4 of Record:
Richard L Jones
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Deed Book No.15-E
Page No. 1588
9 Provide a copy of the most current deed.
Landowner 5 of Record:
Lennar Carolinas LLC
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Deed Book No. 016237
Page No. 00871
9 Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Richard L Jones
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Phone: Office # DB 016264
Mobile # PG 02027
Richard L Jones
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Phone: Office # Estate File: 15-E, 1588
Mobile #
Bluefin Developers LLC
Company 4 Name
Current Mailing Address
City State
Phone: Office # DB 010589
Anthony W Butler
C-mail Address
current Street Address
Zip City State
Mobile # PG 00292
Zip
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # DB 013160 Mobile # PG 02291