NCC231311_FRO Submitted_20230508

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. Project Name M121 Replacement, 2023 Raleigh Phase
2. Location of land-disturbing activity: County Wake City or Township Raleigh
Highway/Street Western Blvd 35.78404° -78.68379°
Latitude(dectmal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: May 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Replacement of Gad
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 11.7 acres
Regular:$1,200
Express:$2,000
6. Amount of fee enclosed Total:$3,200 . 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.
7. Has an erosion and sediment control plan been filed? Yes❑x Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Bob Lepsic, PWS [e-mail]
Address
Phone: Office# N/A Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
KL Platform Owner LLC N/A
Name Phone: Office# Mobile#
4321 Lassiter At North Hills Ave (STE 250) LOPRCL 1 RCMB West Cabarrus Street BM2021
Current Mailing Address Current Street Address
Raleigh NC 27609-5782 Raleigh NC 27609-5782
City State Zip City State
Zip
10. Deed Book No. 018610 02071
Page No. 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 party(ies).
PUBLIC SERVICE COMPANY OF NORTH CAROLINA,INCORPORATED andrew.moore@dom inione n erg y.com
Company Name E-mail Address
P.O. Box 1398 800 Gaston Road, Building A
Current Mailing Address Current Street Address
Gastonia NC 28053 Gastonia NC 28056-9486
City State Zip City
State Zip
Phone: Office# N/A 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:
CT Corporation System [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615- 6417 Raleigh NC
City27615- 6417
State Zip City State
Zip
Phone: Office#N/A Mobile# [phone]
Sherry McGinnes
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City
State Zip
Phone: Office# N/A Mobile# N/A
N/A
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.
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:
HDR Engineering, Inc. [e-mail]
Engineering firm or other consultant E-mail Address
Nathan Willkom, P.E. [phone] [phone]
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(s)
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.
Andrew Moore, P.E. Director - Engineering & Construction
Typ6,/,,,tx
print nameor Authority
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Signature Date
I, Y1 ict �V- /c\J(X � i'
raLIO , a Notary Public of the County of GaS1 itl
State of North Carolina, hereby certify that )r vJ r{) Yv)obrt, 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 3 day of ' , 20 2 3
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CYNTHIA M. ALVARADO i' Nary
NOTARY PUBLIC
Gaston County d 'ob.e.r �- 202C
Seal North Carolina My commission expiresC/
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My Commission Expires 10- - t
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