NCC230473_FRO Submitted_20230217

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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name Bryson's Ridge Lots 1-21
2. Location of land -disturbing activity: County Nash City or Township Spring Hope
Highway/Street
NC 581
Latitude 35.95635 Longitude-78.10752
3. Approximate date land -disturbing activity will commence: January 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 19.93
6. Amount of fee enclosed: $ Previously Paid . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next 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 $2,585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Varnell E-mail Address kvarnell(a�,stocksengineering.com
Telephone [phone] Cell # 252-382-0012 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Axiom Development, LLC
Name
3739 National Drive, Suite 105
Current Mailing Address
919-760-0101
Telephone
3739 National Drive, Suite 105
Current Street Address
Fax Number
Raleigh NC
27612
Raleigh
NC 27612
City State
Zip
City
State Zip
10. Deed Book No. 3154
Page No.
174-177
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.
Starlight Homes North Carolina LLC [e-mail]
Name E-mail Address
4025 Lake Boone Trail, Suite 200
4025 Lake Boone Trail, Suite 200
Current Mailing Address
Current Street Address
Raleigh NC 27607
Raleigh NC 27607
City State Zip
City State Zip
Telephone [phone]
Fax Number
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:
Engineering Firm or other consultant E-mail Address
Individual contact person (type or print) 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 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.
Raymond Rinker VP of Land Development
Type or print name Title or Authority
Signatu V Date
--------- -------; ----------------------------------------------------------------------------------------------------------------------
Hif�
I, a Notary Public of the County of
a R
�j jState of North Carolina, hereby certify that '1°ilI 1t�� Ai . Lllr," 3`L�� 4s';'1�: ` appeared personally
before me this day and being duly sworn ackno ,ledged that thd above form was executed by him.
Witness my hand and notarial seal, this day of ��,������� I '�, 20 n
Notary
SMARY HILL HEROLD
NOTARY PUBLIC My commission expires
WAKE COUNTY, INC
My Commission Expires 9-24-2026

Addendum to FR/O fora Part A, Item 9: Landowner of Record Letter of Consent
Axiom Development LLC
Landowner of Record Name:
Property Tax ID#/PIN:
044084 lots 1-21
Property Address Line 1: 307 N Louisburg Rd, Spring Hope, NC
Property Address Line 2:
City/State/Zip Code:
35.9564,-78.1072
Spring Hope, North Carolina 27882
Applicant submitting plan - must match the financially responsible party named in Part B
Section 1 of the Financial Responsibility/Ownership (FR/O) Form:
Starlight Homes North Carolina LLC
Statement of Landowner Consent: In accordance with NCGS 113A-54.1(a), I hereby declare
that I am the owner or legally authorized representative of the owner of the property described
above and provide my consent for the applicant cited above and in Part B of the FR/O form to
submit a draft erosion control plan to the State of North Carolina and to conduct the planned
land -disturbing activities on the property listed above and in Part A of the FR/O form.
Thomas White
Manager
Type or Print Name Title or Authority
Sign
Date
[e-mail])Gl,�j'�%,_�6I/
Email Telephone

Addendum to FR/O form Part A, Item 9: landowner of Record Letter of Consent
Axiom Development LLC
Landowner of Record Name:
Property Tax ID#/PIN: 007494 lots 22-50
Property Address Line 1: 307 N Louisburg Rd, Spring Hope, NC
Property Address Line 2:
City/State/Zip Code:
35.9564,-78.1072
Spring Hope, North Carolina 27882
Applicant submitting plan - must match the financially responsible party named in Part B
Section 1 of the Financial Responsibility/Ownership (FR/0) Form:
Starlight Homes North Carolina LLC
Statement of Landowner Consent: In accordance with NCGS 113A-54.1(a), I hereby declare
that I am the owner or legally authorized representative of the owner of the property described
above and provide'my consent for the applicant cited above and in Part B of the FR/O form to
submit a draft erosion control plan to the State of North Carolina and to conduct the planned
land -disturbing activities on the property listed above and in Part A of the FR/O form.
Thomas White
Type or Print Name
Signature
Manager
Title or Authority
Date
[e-mail]
Email Telephone