NCC215703_FRO Submitted_20211014

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. Weavers Grove Phase 1
1. Proiect Name
2. Location of land -disturbing activity: County range City or Township Chapel HIII
Highway/Street Sunrise Road Latitude 35.966893 Longitude-79.032363
3. Approximate date land -disturbing activity will commence: Spring 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 26.10
6. Amount of fee enclosed: $ 1,755 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Jennifer Player E-mail [e-mail]
Telephone [phone]x215 cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Habitat for Humanity of Orange County, NC 919-932-7077 x 215
Name Telephone Fax Number
88 Vilcom Center Drive, Suite L110 88 Vilcom Center Drive, Suite L110
Current Mailing Address Current Street Address
Chapel Hill NC 27514 Chapel Hill NC 27514
City State Zip City State Zip
2907, 6628, 4081, 6564. 6646 149, 2237, 332, 388, 1286
10. Deed Book No. Page No. 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.
Habitat for Humanity of Orange County, NC [e-mail]
Name E-mail Address
88 Vilcom Center Drive, Suite L110 88 Vilcom Center Drive, Suite L110
Current Mailing Address Current Street Address
Chapel Hill NC 27514 Chapel Hill NC 27514
City State Zip City State Zip
Telephone [phone]x215 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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in lousiness 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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Jennifer Player
Type or print name
❑igitally signod by Jennifer Player
Jennifer Player ❑a1e:2021.04.0710:39.12-04'00'
Signature
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President/CEO
Title or Authority
41712021
Date
W ,JjkjLdj,cj, , a Notary Public of the County of ChI7-AriM
State of North Carolina, hereby certify that V� appeared
personally before me this day and being duly sworn acknowi dged that the above form was
executed by him.
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