NCC230341_FRO Submitted_20230207

Check if this project is ARPA -funded ❑
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 NameGovernors Club Lot 955
9
3.
4.
5.
6_
7.
8.
*if this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
Location of land -disturbing activity: CountyChatham City orTownshipChapel Hill
`/�/o rt h 35.8443-79.0591
HighwaylStreet LatltUde(decima� degrees} LOngltude{decimal degrees)
Approximate date land -disturbing activity will commence: March 13 2023
Purpose of development (residential, commercial, industrial, institutional, etc.): residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): •45
Amount of fee enclosed: $ 100 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑x No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameStacy E-mail Address
StaC McMillan [e-mail]
Phone: Office # 919.388.3636 Mobile # [phone]
9_ Landowner(s) of Record (attach accompanied page to list additional owners):
Tasrif Ahmed 804.615.5702
Name Phone: Office # Mobile #
111 Majestic Peak Drive same
Current Mailing Address Current Street Address
Garner Same
City nn State Zip City State Zip
10. Deed Book No. G290 Page No.0937 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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financialty responsible party(ies).
Ange Construction dba Ange Signature Homes
Company Name
113 Edinburgh South Drive Suite 100
Current Mailing Address
Cary NC 27511
angeconstruction@bellsouth. net
E-mail Address
Same
Current Street Address
Same
City State Zip City State Zip
Phone: office # 919.388.3636 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:
Elton R Ange III
Name of Registered Agent
113 Edinburgh South Drive Suite 100
Current Mailing Address
Cary NC 27518
City
State
Phone: office # 919.388.3636
[e-mail]
E-mail Address
103 Highclere Lane
Current Street Address
Cary NC 27518
Zip City
Mobile # [phone]
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:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
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.
Ange Signature Homes
Company DBA Name
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 individuals)
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.
Elton R Ange III President
Type or print name Title or Authority
Signature Date
a Notary Public of the County of / /,�IY7
State of North Carolina, hereby certify that L / / I: , , ) � ' / / / appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of _ 2 h4(ALI 20
�Z'
Notary
9 My commission expires - j
Notary Public Z
Durham
County
0
rC A R D"L,`��,�

Continued from Items 9 & 90 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:
Nur Sultana 8046155702
Name Phone: Office # Mobile #
111 Majestic Peak Drive same
Current Mailing Address Current Street Address
Garner NC 27529 same
City State Zip City State Zip
Deed Book No.2290 Page No.0937 Provide a copy of the most current deed.
Landowner 3 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.
Landowner 4 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.
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.

Soil Erosion and Sedimentation Control
C'[ [BAN [ [AM C-()tJN UV
Financial Responsibility/Ownersbip Form
NOT REQUIRED TO BE COMPLETED FOR RESIDENTL4L LOT PERMITS,
PLEASE READ THE FOLLOWING INFORMATION•
1) This section must be signed in the presence of a Notary,
2) This form must be signed by the property owner if an individual. If owned by a company or corporation, this form must be signed by an officer,
director, partner, attorney -in -fact, or other person with authority to execute instruments for the corporation and accompanied by a complete list of all
partners, managing members and registered agents of the company or corporation.
3) This form must also be signed by the financially responsible party and NC agent (if applicable). Same provisions of # 2 above apply,
4) If the landowner and financially responsible parry are different, the completion and signing of this page shall serve as documentation
acknowledging the landowner consents to and authorizes the financially responsible party to undertake the proposed land -disturbing activity on the
landowner's tract(s) of land identified on this application.
5) The information provided on this form is true and correct to the best of my knowledge and belief and was provided by me while under oath.
6) All Land -Disturbing permits are valid for up to (2) years from the date of issuance. If circumstances warrant; the permit may be extended for
(2) years per the conditions of the Chatham County Soil Erosion and Sedimentation Control Ordinance_ Upon the
notice, the Land -Disturbing
permit may be revoked for failure to comply with the Ordinance. If the permit is revoked, all other permits and approvals are withheld until
the property is once again in compliance with Chatham County regulations. Also, upon written notice, a civil penalty (fine) can be instigated
against the property owner and/or additional financially responsible party (if any) for violations of the Chatham County Soil Erosion and
Sedimentation Control Ordinance. This penalty is up to $5000.00 per violation per day and is assessed daily for every day the property is in violation.
Interfering with or hampering an inspection can result in a civil penalty without written notice.
OWNER OF PROPERTY:
Name and Title: Tasrif Ahmed and Nuretabassum Sultana
Company
Signature:
FINANCIALLY RESPONSIBLE PARTY (applicable only if different from property owner):
Name and Title: Elton R Ange III President
Company:
Signature:
NORTH CAROLINA AGENT (if any):
Name and Title:
Company:
Signature:
a Notary Public of fr1 County in the state
of do hereby certify that �nt� AA,a / - / Xg- � i �,inrr personally
appeared before me this day and under oath acknowledged reading the information above and acknowledged thatthe
above form was executed by him or her.
Witness my hand and official seal, this the_. day of / tt 20�)%S.
Notary Pu isblla
My commission expires -1 1,5� (SEA1,) = p TbaTo
count/
Page 3 of 3

G.S. § 1OB41 NOTARIAL CERTIFICATE FOR
ACKNOWLEDGMENT
d4 ve County, North Carolina
I certify that the following person(s) personally appeared before me this day, each
acknowledging to me that he or she signed the foregoing document:
Name(s) of principal(s)
Date: n . Vi 1 Z 3
(Offic�,���A�lYrJ1j�, c�; 4' `try
." �.
`pG� Me�ij��4,��' ffcial Signature afNo aJy
1.y r
N to Public �Z - a1 i. , L , Notary Public
_Durharn - Notary' printed or typed name
ti County _
My commission expires: ' d
,•�f -9 CAR ()V
�JJ1JJ!l111111N����
OPTIONAL
This certificate is attached to a t An_'f, *.signed by r
Tule/Type of Documeod Name of Princip l Signer(s)
on I N' I JlI _ _ , and includes I pages.
Date # of pages

WAKE COUNTY, NC 419
LAURA h RIDDICK
REGISTER OF DEEDS
PRESENTED & RECORDED ON
11/16,o2aeS AT 15:54:55
BOOK:613298 PAGE-92149 — 92150
CORPORATE CERTIFICATE OF AS S 0Mrz0 NAME
PREPARED BY & HOLD FOR BOWEN LAW FIRM PC 44
T`he undersigned corporation, proposing to engage in husine" in WARR _ Caunty,
North Carolina, under an assumed name other than its corporate namia, hcmby certifies th$t-
1_ The name under which the business IS to be conducted is:
ANGE SIGNATURE HONES
(Insert assumed name)
2_ The names and address of the owners} of the business is (are):
ANGE CONSTRUCTION COMPANY 5520 DILLARD DRIVE STE 244 CARY, NC
27518
{Insert name and address of oorporatlon)
Irk witness whereof, this certiftafe is signed in the name of the corporation by its VICE president
this (C day of NOVFMRFR .20
VICE President
State of NC
County of WAKE
I, ELIZABETR WARD BOWEN a Notary Public, do hcroby certify that
ELTON R ANCE III $ personally appoared beforo me
this day of NOVEMER ,, 208., and that they signed the foregoing cer#Ificate on
behalf of the said corporation in rho respective Capacities indicated,
Witness my hand and official saal, this the I C day of NOV'S BER 120 OS
Elizabeth Ward Bowen
(Afrix Notary s^eal}Notary Publ!C
Notary Public ELIZLABE.M WARD BOWEN Wake County. NC
M Commission Expires Oct. 6, 2011
My Commission Expires: ia-o6_2011
MaiJirrg A d&ess, Wake County Ragfsfor of r eads, P. d. Box IS17, Ra)aigh, ABC 2 7602