NCC231274_FRO Submitted_20230522

TOWN OF KNIGHTDALE 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 Town
of Knightdale Unified Development Ordinance before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by Town of
Knightdale, Public Works Department, Stormwater Division. (Please type or print and, if the
question is not applicable, place N/A in the blank.)
Part A.
1. Project Name Knightdale Station Section R4
2. Location of land-disturbing activity: Wake County (Town Limits or ETJ)
Highway/Street Challenger Lane Latitude 35.8007 Longitude -78.4681
3. Approximate date land-disturbing activity will commence: 2022
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):19°
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jonathan Massey E-mail [e-mail]
Phone# [phone] Cell# 919-215-6304
7. Landowner(s) of Record (attach accompanied page to list additional owners):
DFC Knightdale Station, LLC 919-481-300 ch.swan@dfcapitalmanagement corn
Name(s) Telephone E-mail address
14701 Phillips Hwy Ste 300 14701 Phillips Hwy Ste 300
Current Mailing Address Current Street Address
Jacksonville FL 32256 Jacksonville FL 32256
City State Zip City State Zip
8. Deed Book No.018827 Page No.00186-00191 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Jay Lewis-H&H Constructors of Fayetteville, LLC [e-mail]
Name E-mail Address
8601 Six Forks Rd Forum 1, Suite 220 8601 Six Forks Rd Forum 1, Suite 220
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone# [phone]

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Town of Knightdale Erosion and Sedimentation Control Ordinance and/or
Land Disturbance Permit:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone#
(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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone#
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.
Jay C Lewis General Manager
Type or print na e Title or Authority
/I 12 CI,3
Sigryg Date
I, /4t 11 A L , a Notary Public of the County of L'Oetke
State of North Carolina, hereby certify that rLiAG 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 II) day of F-Ciciyicarj , 20 073
ot`�gN,NR'Nh��14,
s�e<�y,,,A , _• Notary
My commission expires /12.93/)
My Comm.E�P
111231202 r'
a •