NCC220377_FRO Submitted_20220120

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. Rosemont Lot 55
1. Project Name
2. Location of land -disturbing activity- County Chatham City or Township Durham
HighwaylStreet
Royal Sunset Latitude 35.848057Longitude -78.916211
3. Approximate date land -disturbing activity will commence: 1-31-22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.09
300
6. Amount of fee enclosed: $ 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:
Jeremy Fisher [e-mail]
Name E-mail Address
919-704-1985 919-704-1985
Telephone Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
John F Rodgers 919-795-8903
Name Telephone Fax Number
417 W Peace Street 417 W Peace Street
Current Mailing Address Current Street Address
Raleigh, NC 27603 Raleigh, NC 27603
City State Zip City State Zip
2127 0537
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.
Kodiak Contracting LLC [e-mail]
Name E-mail Address
555 S Mangum Street - Suite 100 555 S Mangum Street - Suite 100
Current Mailing Address
Durham, NC 27701
Current Street Address
Durham, NC 27701
City State Zip City State Zip
919-704-1985 N/A
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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address
N/A
City State Zip
N/A
Telephone
Current Street Address
N/A
City State Zip
Fax Number
N/A
(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:
Jeremy D Fisher jdCa?kodiakcontracting.com
Name of Registered Agent
5704 Wanderlust Lane
Current Mailing Address
Durham, NC 27712
City State Zip
919-236-3074
Telephone
E-mail Address
5704 Wanderlust Lane
Current Street Address
Durham, NC 27712
City State Zip
N/A
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.
Jeremy D Fisher
Type or pr n e
Signature
--------------------------------------------------------------
LLC Proprietor
Title or Authority
V'+ `sue-' Z-vwz
Date
--------------------------------------------------------------
I • vy � a Notary Public of the County of vV'k `l16
State of North Carolina, hereby certify that 'jt2 � D • q St`-'tV 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 l,4-1
day of KJ 20
JANET WEST
NOTARY PUBLIC Notary
Seal Y WAKE COUNTY, NC
M Commission Expires 522-2026.
My C4
on expires 0 r - �-') - � �_ Q ,