NCC230054_FRO Submitted_20230110

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 N/A in the blank.)
Part A.
1
2.
3.
4.
5.
6.
7
Project Name Cedar Creek Apartments
Location of land -disturbing activity: County Franklin City orTownshipYOungsyllle
Highway/Street Cedar Creek Road Latltude(decimaldegrees) 36.03628 Long ltude(decimaldegrees)
Approximate date land -disturbing activity will commence: 10/20/2022
-78.45398
Purpose of development (residential, commercial, industrial, institutional, etc.). Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas). 6.7 J.
Amount of fee enclosed $2,450 . 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.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Michael Hurt E-mail Address [e-mail]
Phone: Office #
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Hurt LLC
Name
PO Box 9038
Current Mailing Address
Rocky Mount NC
City State
10. Deed Book No. 2237
252-714-3710
Phone: Office # Mobile #
201 N. Winstead Avenue - Suite D
Current Street Address
27804 Rocky Mount NC 27804
Zip City
Page No. 764
State
Zip
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 pa►fy(ies).
Hurt LLC
Company Name
PO Box 9038
Current Mailing Address
Rocky Mount NC 27804
City
Phone: Office #
State Zip
[e-mail]
E-mail Address
201 N. Winstead Avenue - Suite D
Current Street Address
Rocky Mount NC 27804
City State Zip
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:
Michael Hurt [e-mail]
Name of Registered Agent E-mail Address
PO Box 9038 201 N. Winstead Avenue - Suite D
Current Mailing Address Current Street Address
Rocky Mount NC 27804 Rocky Mount NC 27804
City State Zip City State Zip
Phone: Office # Mobile # [phone]
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City
Phone: Office #
State
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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.
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:
Mack Gay Associates, P.A. [e-mail]
Engineering firm or other consultant E-mail Address
Scott Bumgarner 252-446-3017
Individual contact person (type or print) 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
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
Corr c d inform Lion shopulp the a be any change in the information provided herein.
Ty or 40116ame - -. - Thle-or Aut ri . - --
gnature -� - Date -
I. ni rk a Notary Public of the County of
State of North Carolina, hereby certify that _ftelne,& l 3, pr} 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 day of ,Se _ 20Z_
ANaELA M CLARK Notary
Nor��R_Y _P suc
NASH CQ11N't�9pb CAROLINA
My COMMISSIONEXPIRES i D. My commission expires

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Marshall Wiggins
Name Phone: Office # Mobile #
414 S. White Street Apt. 301 414 S. White Street Apt. 301
Current Mailing Address Current Street Address
Wake Forest NC 27587 Wake Forest NC 27587
City State
Deed Book No. 2237
Landowner 3 of Record.
Youngsville Academy
Name
2045 Hicks Road
Zip City State Zip
Page No. 764 Provide a copy of the most current deed.
Phone: Office # Mobile #
2045 Hicks Road
Current Mailing Address Current Street Address
Youngsville NC 27596 Youngsville NC 27596
City State
Deed Book No. 2252
Landowner 4 of Record:
Zip City
Page No.1467
State Zip
Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No- Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
City
Phone: Office #
Company 4 Name
Current Mailing Address
City
Phone: Office #
Company 5 Name
Current Mailing Address
E-mail Address
Current Street Address
State Zip
State Zip City State
Mobile #
E-mail Address
Current Street Address
State Zip City State
Mobile #
E-mail Address
Current Street Address
Zip
Zip
City State Zip City State Zip
Phone: Office # Mobile #