NCC222704_FRO Submitted_20220817

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1
2
3
Project Name Lambeth, Latimer, & Reynolds Sidewalk Project
Location of land -disturbing activity: County Wake City or Township Raleigh
ramtieth o,,ve,Lat,mer RoadrReYnvlds Road 35.84126
Highway/Street Latltude(decimal degrees) Longitude(decimal degrees)
Approximate date land -disturbing activity will commence: August 12, 2022
-78.63563
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Sidewalk Installation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.32
6. Amount of fee enclosed $1050 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900), Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJake Ray E-mail [e-mail]
Phone: Office # 919-996-4108 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attached
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State
Zip City
State
Zip
10. Deed Book No. Page No. 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 names) of the owner(s) may be listed as the financially responsible party(ies).
City of Raleigh
Company Name
P.O. Box 590
Current Mailing Address
Raleigh NC 27601
City State
Phone: Office # 919-996-5575
Zip
Richard. [e-mail]
E-mail Address
222 West Hargett Street
Current Street Address
Raleigh NC 27601
City State Zip
Mobile #
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:
Marchell Adams -David [e-mail]
Name of Registered Agent E-mail Address
222 W. Hargett St. 222 W. Hargett St.
Current Mailing Address
Raleigh NC 27601
City State Zip
Phone: Office # 919-996-3070
Current Street Address
Raleigh NC 27601
City
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:
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
(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

Continued from Items 9 & 90 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 #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 3 of Record:
Mobile #
State Zip
Provide a copy of the most current deed.
Name Phone: Office #
Current Mailing Address
City State
Deed Book No.
Landowner 4 of Record:
Current Street Address
Mobile #
Zip City State Zip
Page No. Provide a copy of the most current deed.
r,
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
p
Deed'Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office # Mobile #
Current Mailing Address
City State
Deed Book No.
Current Street Address
Zip City
Page No.
State Zip
Provide a copy of the most current deed.

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If 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:
City of Raleigh
Engineering firm or other consultant
Jake Ray, PE
Individual contact person (type or print)
jacob. [e-mail]
E-mail Address
919-695-6051 919-695-6051
Phone: Office # Mobile #
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
corrected information should there be any change in the information provided herein.
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Type or_print name Title or Authority
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Signa u Date
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1, V 1 a Carf)V6_11- GLNIC17N'otary.Public of the County of �,� DL P_
State of North Carolina, hereby certify that 1 i� Yet L •Plel I 1.t appeared personally
before me this day and being duly sworn acknowledged that the above form as executed by him/her.
on e_1
Witness my hand and notarial seal, this 2 day of Irk 20 o
Notary
B LZ. L '- o�Q
�OTAR}My commission expires
Comm. P. I P
z 9-14-2022
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Continued from Item 9 in Part S of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
City State
Phone: Office #
Company 5 Name
Current Mailing Address
City State
Phone: Office #
E-mail Address
Zip
Zip
Current Street Address
Zip City State Zip
Mobile #
E-mail Address
Current Street Address
Zip City State Zip
Mobile #