NCC240177_FRO Submitted_20240122

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 Franklin Townehomes
2. Location of land-disturbing activity: County Johnston City or Township Smithfield
Highway/Street Wilson's Mill Road Latitude N 35D 32' 00.43" Longitude W 78D 21' 16.45"
3. Approximate date land-disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 16 AC
6. Amount of fee enclosed: $1,600. The application fee of$100.00 per acre(rounded up to the next
acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
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 Jeremy Keeny, PE, PLS E-mail Address [e-mail]
Telephone [phone] Cell # Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Market Street 1500, LLC 919-446-6865
Name Telephone Fax Number
PO Box 2346 PO Box 2346
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield NC 27577
City State Zip City State Zip
10. Deed Book No.4643 Page No.450-462 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.
R&R Development Group of NC, LLC [e-mail]
Name E-mail Address
1611 Jones Franklin Road 1611 Jones Franklin Road
Current Mailing Address Current Street Address
Raleigh NC 27606 Raleigh NC 27606
City State Zip City State Zip

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:
Rob Bailey [e-mail]
Name of Registered Agent E-mail Address
1611 Jones Franklin Road 1611 Jones Franklin Road
Current Mailing Address Current Street Address
Raleigh NC 27606 Raleigh NC 27606
City State Zip City State Zip
Telephone [phone] 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.
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Type print name { Title or Authority
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nature Date
I, I la►ry l�(I (T0 '0( , a Notary Public of the County of PA IL&
State of North Carolina, hereby certify that R0 b44 + Ba of e\/ appeared
personally before me this day and being duly sworn acknowledged that he above form was executed
by him.
Witness my hand and notarial seal, this ( 0 day of F-W ru Ay'y , 20
• 101, (9147)J_
MARY
K CLIFFORD
Seal 67/((--
NOTARY PUBLIC • Notary
WAKE COUNTY ► F„ L - /� �O 0
STATE OF NORTH CAROLINA My commission expires C� , Y-
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