NCC222084_FRO Submitted_20220604

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project NameLot 1 @ Pennington @ Jordan Lake
2. Location of land -disturbing activity: CountyC'hatharn City or TownshipPlttsboro
Highway/Street Gentry Drive Latitude(decimal degrees) 35.739 Long itude(decimal degrees)-79.068
3. Approximate date land -disturbing activity will commence: CD-13 �71 a
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
100 00
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-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes x❑ Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameScott Barnes
Phone: Office # N/A
E-mail [e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
W.T. Barker Construction
Name
919-625-5617
Phone: Office # Mobile #
1401-113 Sunday Drive 1401-113 Sunday Drive
Current Mailing Address Current Street Address
Raleigh NC 27607 Raleigh NC 27607
City State Zip City State Zip
10. Deed Book No. U� 1 (0 Page No. O Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
W.T. Barker Construction Company
Company Name
1401-113 Sunday Drive
Current Mailing Address
Raleigh NC 27607
City
Phone: Office #
State
Zip
Will [e-mail]
E-mail Address
1401-113 Sunday Drive
Current Street Address
Raleigh NC 27607
City State
Mobile # [phone]
Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
r4
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
01A
Name of Registered Agent
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
N�
Company DBA Name
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(s)
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 Party). I agree to provide
correcte information should there be any change in the information provided herein.
Typ or print n Title or Authority
7
6&-
Signa ure Date
------------------------------------------------------------------------------------------------------------------------------------
I, ' a Notary Public of the County of
State of North Carolina, hereby certify that /,/!�/C P appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of 20
otary
Seal
My commission expires '
0,, STACY A WACHTEL
'� P= Notary Public, North Carolina
Wake County
ti My � m fission Expires

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
014 -
Company Name E-mail Address
Current Mailing Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name E-mail Address
State
Zip
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Street Address
Current Mailing Address
City State Zip
City State Zip
Phone: Office #
Mobile #
N 16
Company 5 Name E-mail Address
Current Mailing Address
Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Deed Book No. Page No.
Provide a copy of the most current deed.
Landowner 3 of RecO d:n
j"►
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Deed Book No. Page No.
Provide a copy of the most current deed.
Landowner 4 of Reco
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Deed Book No. Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
1 v
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State Zip City State Lip
Deed Book No. Page No. Provide a copy of the most current deed.

FILED ELECTRONICALLY
CHATHAM COUNTY NC
LUNDAY A. RIGGSBEE
REGISTER OF DEEDS
uoise Tax:: $3Oco t .
Real &Weldedt'tfierft. Q.W7347
mail/l3dxto: G tee.
`I'liil tri5trt Ment waS preirared by:. yr v_thpqttjttjgoilkabPOW611 of - adv%-
13i.iefiiesct pttgilfcsxtli$r d ':'1..:Gen ,. rtv t P 6
TH •MMmade tftis,7ff --_of Way, 2621,:by:a W baweon:
cootefttnea Creek l}aYuT(+Pm t ! y`r
a Nixrt�l.lYitrnliitA. �iax�iar4tie�ia
8SD2 .W Slg f6k.1 S Rdiiii,
2aleig�,:l"�tG 2?615
FILED May 21, 2021
AT 03:15:14 PM
BOOK 02216
START PAGE 0688
END PAGE 0690
INSTRUMENT # 08136
EXCISE TAX $306.00
"Vir:T *ruercous ructl?A o psny,
i 1'4t►t�th,Ca:jraisa cu>+porafiori
140T Sgnday UrivOi 5luith 115
l�il�li; NG'276(!'7
inter in appropt ate. block,for each :Gmtor and, Grantm,: rtame, rttatliilg: address, aril; if appropriate, character -of entity;, e:g.
aoz crrati or >trttzer�t% ;
Tie clesigritiibia Giepnoi auii C:rtt:a used lxari shall iticiuic said Paitiz rlaexi' fib}rs; swcoesirct'sigri,ncl shah ixclucl
singulax, plural; Masculine; fomittine otiieuter aas:tequired by wiltext
W1TNE�a'"�TI4, that the t#te Gianteo, ,tt a receipt of.which is k►eroy acknowl'edSed,has
tinci by tlxase:prescs► .d+�os gt t, batgatn 'sell imd-c*ftvqy, unto tlia Girarrtea tn:fec simple, all ihtSset cesi€na�lbabr parcels of late siiitated
iii:'the.City+:o:f`!?�ittgboro; Gltathatn:GoutYtj!,NorthCArbikWAnd more partt�ilarly<dtscribed asfgila*s:
The.property horoinAbove descr.'ib ivas :0tlt ft*0:kry G!" for b instriurtent rc or itt:,l ocik 277,. Pao 866,::+Cht6aril CQiirity.
Rw:gistry;
All or a�potlioh ot"tlitiproliect-. he+rorn i0it �eyeitcti4e8 itt include tide primary resYdence_of a Grantor;
A map showing:the:.abbve,de ri6ed-piaperty.is;reio. ed.inl'intSlide 2646-1:6,_0 atham. Oounty Rogistr s:.
TO HAVE AND TCi:HOLD the.aforesaid lot orpatcel.of landlandali-iriv`ileges to the Grantee in
fee simple.
hit" Bar Ass�cialaoii •Firriri Nty. 3 � } 9'76: Rii+ised .� }!}?2U16
PririWd by. eeehcnl viith tM NC Bar Ask4daiiDn
Submitted electronically by "Pinna, 7ohnston & Burwell, PA"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Chatham county Register of Deeds.

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