NCC231113_FRO Submitted_20230420

EXPRESS REVIEW
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 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 Elizabeth Street Apartments
2. Location of land-disturbing activity: County_Dur lam City or Township Durham
Highway/Street_574 Liberty St. Latitude_35.992904° Longitude_-78.892198°
3. Approximate date land-disturbing activity will commence: June 1, 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.):_Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.59
6. Amount of fee enclosed: $_1,575 . The application fee of$65.00 per acre (rounded plus$250/
ac for
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585). express
review
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: _Noel Henderson-James E-mail Address_nhenderson-iamesalaurelstreetres.com
Telephone [phone] Cell# 504-258-4638 Fax# N/ A
9. Landowner(s)of Record (attach accompanied page to list additional owners):
_Housing Authority of the City of Durham 919-683-1551 N/A
Name Telephone Fax Number
_330 E. Main St P 021x 1726
Current Mailing Address Current Street Address
_Durham NC 27702 Durham NC 27702
City State Zip City State Zip
10. Deed Book No._363 Page No. 225 Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(s) who are financially res onsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or film is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
_Laurel Street Residential, LLC nhenderson-jameslaurelstreetres.com
Name E-mail Address
2132 Thrift Road. Suite A N/A
Current Mailing Address Current Street Address
Charlotte, NC 28208 N/A
City State Zip City State Zip

Telephone [phone] Fax Number N/A
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
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
corrjrected information should there be any change in the information�prlovided herein. .-P ,N f7-
Type or pri Title or Authority
/2.1 2-(
Date
I, /4/ e L Vt, v w v, , a Notary Public of the County of -(7:Cavt &i
State of Ohio, hereby certify that t d Vt C,1 C 1'<< W c.T 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 2 , day of A4cky , 20 a
\ : ALEC VERNON Notary
`- , *!e4tlotary Public,State of Ohio ` , I as
oe My Comm. Expires July 16,2025 My commission expires - �s k r