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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 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 N/A in the blank.)
Part A.
1. Project Name Golden Ridge Subdivision
2. Location of land -disturbing activity: County Franklin City or Township
Highway/Street Mays Crossroads Road Latitude 36.031820 Longitude-78.418644
3. Approximate date land -disturbing activity will commence: January 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 79.69 AC
6. Amount of fee enclosed: $ 5,200 . 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 Dennis Cyrus E-mail Address dennis@grandemanorhomes.com
Telephone 919.669.5933 Cell # n/a Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Twin Circles, LLC n/a n/a
Name Telephone Fax Number
2202 Tar River Road n/a
Current Mailing Address Current Street Address
Creedmoor NC 27522 n/a n/a n/a
City State Zip City State Zip
10. Deed Book No. 2263 Page No. 286.287 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
C&E Real Estate, LLC dennis@grandemanorhomes.com
Name E-mail Address
2202 Tar River Road Same
Current Mailing Address Current Street Address
Creedmoor NC 27522
City State Zip City State Zip
Telephone 919.669.5933 Fax Number n/a
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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
E-mail 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
Current Mailing Address
City State
Telephone,
E-mail
Current Street Address
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
corre ed information ou� there be any change in the information provided herein.
Type or p n - TTit ear Authority
gna ure Date
a Notary Public of the County of✓�
State of North Carolina, hereby certify that DA V1 b Cvru- S appeared
personally before me this day and being duly sworn acknoow edged that the above form was
executed by him.
Witness my hand and notarial seal, this day of 20
Notary
Amy L Warren My commission expires 0310a-{,�
NOTARY PUBLIC
Wake County, NC
i<4y Commission Expires February 2, 2023
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