NCC223916_FRO Submitted_20221122

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FINANCIAL RESPONSIBILITWOWNERSHIP 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 Environment and Natural Resources. (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.
1. Project Name Westra Subdivision Phase 1
2, Location of land -disturbing activity: County Franklin City or Township
Husketh Road 35..03058-78.43424
Highway/Street Latitude Longitude
3. Approximate date land -disturbing activity will commence: June 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc,);
Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 32.18
6. Amount of fee enclosed: $2,145 . 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:
Name Dennis Cyrus E-mail Address [e-mail]
Telephone 919,669.5933 Cell # n/a Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Husketh Road LLC n/a n/a
Name Telephone Fax Number
1151 Tarboro Rd 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. 2192 Page No.1561 - 1564 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Husketh Road LLC [e-mail]
Name E-mail Address
1151 Tarboro Rd Same
Current Mailing Address
Youngsville NC
City State
Telephone 919,669.5933
Current Street Address
27596
Zip City
Fax Number n/a
State Zip
1 of 2 4/16/2021, 10:57 AM

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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
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
Patty 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
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 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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
AV V '0/1 / ��
Type or pn Title or Authority
Signature Date
I, �]�YY�rvl Id a Notary Public of the County ofOnlc,�� h
State of North Carolina, hereby certify that —..1� a �. appeared
personally before me this day and being duly sworn acknowledged ghat the above form was
executed by him.
Witness my hand and notarial seal, this 20 day of-Q,r-. 20�
'�111111!l1���I!
2 A Af ire Nota
Se
A R Y _ My commission expires
PUBLIC 0i
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