NCC221242_FRO Submitted_20220413

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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. Sutherland Phase 1
1. Project Name
2. Location of land -disturbing activity: County Franklin County City or Township Franklinton
Highway/StreetPocomoke Road Latitude36.083772 Longitude-78.511636
3. Approximate date land -disturbing activity will commence: February 18th
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.5 Acres
6. Amount of fee enclosed: $2,450.00 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes N/A No NIA Enclosedx
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Stan KleSta E-mail Address [e-mail]
Telephone NIA cell # 910-322-6214 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Caviness & Cates
Name
639 Executive Place, Suite 400
Current Mailing Address
Fayetteville, NC 28305
City
910-322-6214
Telephone
NIA
Fax Number
639 Executive Place, Suite 400
Current Street Address
ayetteville, NC 28305
State Zip City
State
Zip
10, Deed Book No, Page No. Provide a copy of the most current deed,
Part S.
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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible pafty.
Caviness & Cates [e-mail]
Name E-mail Address
639 Executive Place, Suite 400
Current Mailing Address
Fayetteville, NC 28305
City
State Zip
639 Executive Place, Suite 400
Current Street Address
Fayetteville, NC 28305
City
Telephone [phone] Fax Number NIA
State
Zip

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:
NIA NIA
Name E-mail Address
NIA NIA
Current Mailing Address Current Street Address
NIA NIA
City State Zip City State Zip
Telephone N/A Fax Number NIA
(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:
NIA
NIA
Name of Registered Agent
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State
Zip City State Zip
Telephone NIA
Fax Number NIA
(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:
The Nau Company, PLLC
[e-mail]
Engineering Firm or other consultant
E-mail Address
Timothy P. Nau, PE
919-625-3090 NIA
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 Financlally Responsible Person), l agree to provide corrected information should there be
any change in the information provided herein.
Christopher E. Cates
Type or print nam
Sign
Vice President
Title or Authority
- 1 Nq � a ;��
©ate
1 Pamela M Geddie , a Notary Public of the County of Cumberland
State of North Carolina, hereby certify that Christopher E. Cates 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 4' day of 20;D,=
1
Seal = Q4 t3otorY PUptic
Curr�!oertanox�'tres= My commission expires May 22, 2026
MY CO mission s`:
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