NCC221018_FRO Submitted_20220314

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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.
1. Project Name Smithfield Police Expansion
Location of land -disturbing activity: County Johnston
Highway/Street S. Fifth St.
Latitude 35.5089667
City or Township Smithfield
Approximate date land -disturbing activity will commence: January 2022
Longitude-78.343911
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12
6. Amount of fee enclosed: $ 200 . The Express Permitting (EP) application fee is a
dual charge. The standard fee of $100.00 per acre (rounded up to the next whole acre) is assessed
without a ceiling amount. In addition, the EP supplemental fee is $250.00 per acre up to eight acres,
after which the EP supplemental fee is a fixed $2,000.00 (Example: 8.2 acres total is $2,900).
7. Has an erosion and sediment control plan been filed? Yes x No Enclosed x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Todd Waddell E-mail Address [e-mail]
Telephone [phone] Cell # 919.369.7955 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Smithfield 919.934.2116
Name Telephone
PO Box 761
Current Mailing Address
Smithfield, NC 27577
City
10. Deed Book No. 01475
DB 04803 PG 0045
350 E. Market St.
Current Street Address
Smithfield, NC 27577
State Zip City State
N/A
Fax Number
Zip
E&F Property: DB 04676 PG 0059
Provide a copy of the most current deed.
DB 0815 PG 662
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.
_ Page No. 0170
DB 01256 PG 0848
APR Restoration and Commercial Development [e-mail]
Name E-mail Address
9316-4 Smart Dr. 9316-4 Smart Dr.
Current Mailing Address Current Street Address
Raleigh, NC 27603 Raleigh, NC 27603
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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
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 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:
n/a
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Timmons Group [e-mail]
Engineering Firm or other consultant E-mail Address
Garrett Frank 919.866.4503 919.859.5663
Individual contact person (type or print) 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 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.
Todd Waddell President of Commercial Operations
Type r print name Title or Authority
Signature Date
1, A. r �.J .� _ �1C_ VI ���7 a Notary Publi of the County of
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State of North Carolina, hereby certify that if � 0 �, .v ,! if ./ - appeared personally
before me this day and being duly sworn ack wledged that the above form was executed by him.
�? ,n ,•�, I , 20 2
Witness my hand and notarial seal, this �I _d y of Cil�� t�.�.,y
I'dti 'r � al4v
MELISSA RHODES Notary
N
ovary r- c, North Carolina
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My Commission Expires My commission expires
October 27, 2021