NCC216170_FRO Submitted_20211105

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -di sturbing 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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name The Reatreat at Green Haven (P as& Z : L a fa ! � S6 }
2. Location of land -disturbing activity: County Franklin City or Township Youngsville
Highway/Street Green Haven Blvd. Latitude 36.039593 Longitude-78.529776
3. Approximate date land -disturbing activity will commence: September 22, 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 31.28 Acres
6. Amount of fee enclosed: $ 2'080 . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andy Crawford E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
J77's- u✓ ZL C
yL,. _
Name // Te eph one Fax
ll
Current Mailing Address Current Street Address
efa-,-y A 7519
City State Zip City State
Number
Zip
10. Deed Book No.2136 Page No. dos ZOd Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are fina ncially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Eastwood Homes of Raleigh, LLC [e-mail]
Name E-mail Address
6601 Six Forks Road, Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27615
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 Pa rtnership 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 State Zip
Telephone
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 b e 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 F inancially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Andy Crawford Vice President
Typeorprint names f
Signodre Date
Title or Authority
1, n_yuf AMAI. a Notary Public of the County of
, LL� 9—
State of North Carolina, hereby certify that I \ c 1 c ucAr appeared
personally before me this day and being duly sworn ac knowledge that the above form was
executed by him,
Witness my hand and notarial seal, this S day of20
Notary
Seal c
My m�n`S�i WHEY = commission expires
�ro�.