NCC223206_FRO Submitted_20220913

1� •
"' • FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity that disturbs one or more acres as covered by the Town of
Clayton Soil Erosion and Sedimentation Control Ordinance before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Clayton. Lots smaller than one
acre that are part of a larger plan of development are also subject to Town of Clayton Soil Erosion and
Sedimentation Control Ordinance and are required to complete this form. (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.
i
6
3
Project Name Highgate Phase 5
Location of land -disturbing activity: County JOHNSTON City or Township CLAYTON
Highway/Street
Shohvell Road R Covered Bridge Road Latitude 35.6735Longitude -78.4750
Approximate date land -disturbing activity will commence: December 11, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12
6. Has an erosion and sediment control plan been filed? Yes No Enclosed ✓
7
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Gray Methven E-mail Address [e-mail]
Telephone N/A cell # 919-398-3371 Fax # N/A
8. Landowner(s) of Record (attach accompanied page to list additional owners):
Everland-Lee LLC 919-639-2073 919-639-8841
Name Telephone Fax Number
104 State Avenue, Suite 103 104 State Avenue, Suite 103
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC 27520
City State Zip City State Zip
9. Deed Book No. 02916 Page No. 0504 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firms) 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.
Wakefield Development
Name
3100 Smoketree Court, Suite 210
[e-mail]
E-mail Address
3100 Smoketree Court, Suite 210
Current Mailing Address Current Street Address
Raleigh NC 27604 Raleigh NC 27604
City State
Telephone [phone]
Zip City
Fax Number N/A
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:
N/A
N/A
Name
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A N/A N/A
N/A N/A N/A
City State Zip
City State Zip
N/A
N/A
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:
Gray Methven
[e-mail]
Name of Registered Agent
E-mail Address
3100 Smoketree Court, Suite 210
3100 Smoketree Court, Suite 210
Current Mailing Address
Current Street Address
Raleigh NC 27604
Raleigh NC 27604
City State Zip
City State Zip
919-398-3371
N/A
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.
e!:5e qy MeTV V6AJ
Type or print n e
Signature
--------------------------------------------------------------
Title or Authority
Date
a Notary Public of the County of WCJA,--
State of North Carolina, hereby certify that W P+L Qe" 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 I day of 20 2.)
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Everland-Lee LLC
104 State Avenue, Suite 103
Clayton, NC 27520
November 11, 2021
Wakefield Development
3100 Smoketree Court, Suite 210
Raleigh, NC 27604
Re: Highgate Phase 5
Johnston County
To whom it may concern:
This letter gives Wakefield Development authority to pursue plan approvals for erosion and sediment
control plans for the Highgate Phase 5 development, located at Shotwell Road and Covered Bridge Road
in Clayton, NC. We also give permission for Wakefield Development to perform construction on this
property.
Please contact me at 919-639-2073 or [e-mail] with any questions.
Sincerely,
�e�lalie G. stanc�G
Freddie Stancil
Everland-Lee LLC