NCC243615_FRO Submitted_20241121

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. Collins Park Lot 2B - Shoppes at Collins Park
1. Project Name
2. Location of land-disturbing activity: County Wake City or Township Holly Springs
2201 Ralph Stephens Rd. 35 6326 -78.8304
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence:08/28/2024
4. Purpose of development(residential, commercial, industrial, institutional,etc):Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 1.42
6. Amount of fee enclosed: $ 150.00 . The application fee of$100.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example:8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes X _ No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name Chip Young (Superintendent) E-mail Address cyoung@focusdesignbuilders corn
Telephone[phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners).
Vishesh Panjwani ( CP-HS 2B Holdings, LLC) [phone]
Name Telephone Fax
9133 Fawn Hill Court 9133 Fawn Hill Court
Current Mailing Address Current Street Address
Raleigh, NC 27617-7769 Raleigh, NC 27617-7769
City State Zip City State Zo
10. Deed Book No. Page No. Provide a copy of the most current ceec
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Pro. de a
comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole propr e:z•
the name of the owner or manager may be listed as the financially responsible party.
CP-HS 2B Holdings, LLC [e-mail]
Name E-mail Address
9133 Fawn Hill Ct 9133 Fawn Hill Ct
Current Mailing Address Current Street Address
Raleigh, NC 27617-7769 Raleigh, NC 27617-7769
City State Zip City State Zip
Telephone[phone] 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 State Zip City S'a!e Z
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was
by me under oath (This form must be signed by the Financially Responsible Person if an - a
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered ages:
the authority to execute instruments for the Financially Responsible Person). I agree to prc, �e
corrected information should there be any change in the information provided herein.
Vishesh Panjwani Owner
Type or print name Title or Authority
_ 08-29-2024
Signature Date
\NjqA k e.( , a Notary Public of the County of v .Ake_
State of North Carolina, hereby certify that V 15V) Pr"^�6'.00kA 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 I day of CA,IyAs-1- , 20 2_
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YtOt a u r4rvrCaj
4"rAltan. km Notary
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