NCC230401_FRO Submitted_20230223

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT DEC
EXPRESS PERMITTING OPTION 11192021
No person may initiate any land -disturbing activity on one or more acres as covered#Yq#i"b
this form and an acceptable erosion and sedimentation control plan have been completed and ap rovW dffi-co
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 NIA in the blank.)
Part A. New Liberty Subdivision
i . Project Name
2. Location of land -disturbing activity: County Franklin City or Township
NC Highway 96 36.0683° N 78.5254' W
Highway/Street Latitude Longitude
3. Approximate date land -disturbing activity will commence: February 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16.00 AC
6. Amount of fee enclosed: $ $3,600 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per 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 $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
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
Jason Morrow E-mail Address [e-mail]
Telephone nla Cell # 919 744 9949 nla
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Liberty Lucky Seven LLC 919-744-9949 nla
Name Telephone Fax Number
5711 Six Forks Road Suite 200 5711 Six Forks Road Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
2267 414
10. Deed Book No. Page No. 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 fimn is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Liberty Lucky Seven LLC [e-mail]
Name E-mail Address
5711 Six Forks Road Suite 200 5711 Six Forks Road Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
919-744-9949 n!a
Telephone 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
Telephone
State
Zip
City State Zip
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:
FLM Engineering, Inc [e-mail]
Engineering Firm or other consultant
Chase Massey, PE
Individual contact person (type or print)
E-mail Address
919-423-8975
nla
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.
Jason Morrow
Type or print
nature
Title or Authority
Date
I. a Notary Public of the County of
State of North Carolina, hereby certify that j# M ?` O-6 V) 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
Seal
CATHERINE MARIE WITTENBERGER
Notary Public, North Carolina
Wake County
My Commission Expires
May 04. 2026
day of 20
Notary
My commission expires 4