NCC223321_FRO Submitted_20220922

FINANCIAL RESPONS113ILITYIOWNERSHIP 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. Project Name NC Veterans Park PH II
2. Location of land -disturbing activity: County Cumberland City or Township_ Fayetteville
Bragg Blvd. 35.059-78.885
Highway/Street Lalitllde(�tecimaldegraosj Longilude(dec#n}aldngraos)__
3. Approximate date land -disturbing activity will commence: September 2022
.4. Purpose of development (residential, commercial, industrial, institutional, etc,): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.00
6. Amount of fee enclosed $2,800.00 . 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 $260 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 ® No ❑
8. Person to contact should eroslon and sediment control Issues arise during land -disturbing activity:
Name John Cooper E-mail Address [e-mail]
Phone: Office ## 919-777-2826 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Fayetteville
Name
433 Hay Street
Current Mailing Address
Fayetteville, NO 28301
910-433-1359
Phone: Office #
433 Hay Street
Current Street Address
Fayetteville, NO 28301
NIA
Mobile #
City State Zip City State Zip
11555 0402
10. Deed Book No. 09303 Page No. 0100 Provide a copy of the most current deed.

Part B.
1. Company(les) 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 proprlelorship or if the landownor(s) is
all Individual(s), the namo(s) of tho owner(s) may be listed as the firmnclaily responsible pady(les).
City of Fayetteville
Company Narne
433 Hay Street
Current Mailing Address
Fayetteville, NC 28301
City State Zip
Phone: Office # 910-433-1990
[e-mail]
E-mail Address
433 Hay Street'
Current Street Address
Fayetteville, NC 28301
City State Zip
Mobile # NIA
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,
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
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
city
Phone: Office It
E-mall Address
Current Street Address
State zip City
Mobile #R
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
Partnership, or oher company not registered and doing business under an assumed name, attach a copy
/ f the C rtifica�4 f Qmed Nat -no.
r V
y qfi Fayettevill , NC
(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;
SEPI Engineering & Construction [e-mail]
Engineering firm or other consultant
Martin A. Hebrank, PE
Individual contact person (type or print)
E-mail Address
919-747-5877
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,
Tye r prinj nape Title or Authority
nn A
I I
Date
p jPaV '' I�C� 0- A i , a Notary Public of the County of C'V h�ej
State of North Carolina, hereby certify that �'1-(� appeared personally
before me this day and being duly sworn acknowledged that the abov form was executed by him/her.
Witness my hand and notarial seal, this Ld3UY
ay of�, 20 z�
Notary
Pamela b 1c �' n _ O ZOO
e�)iotary Public My commission expires ,
umberiand County �—
North Carollna

Contlnued from Items g & 10 In Pert A of the Financial Responsibility/Ownership Form for multiple
owners. Attach coples of this page as needed to list all. landowners.
Landowner 2 of Record:
Narne
Phone: Off€ce it 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 record:
Name Phone: Office It Mobile #
Current Malling Address Current Street Address
City State Zip City Slate Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office It 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:
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.

Continued from Item 1 in Part B of the financial Responsibility/Ownership Form for rnuftiple pa►fies.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
City
Phone: Office #k
State
f=-mail Address
Current Street Address
zip City State zip
Mobile It
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State zip City State Zip
Phone: Office #I . Mobile #
Company 4 Name
E-mail Address
Current Mailing Address Current Street Address
City State zip City State Zip
Phone; Office it Mobile #
Company 6 Name E-mail Address.
Current Mailing Address Current Street Address
City State zip City State Zip
Phone: Office #k Mobile #

Deanna Muff
From: Deanna Wiuff
Sent: Monday, September 19, 2022 9:31 AM
To: Kimberly Toon
Subject: FW: Away from the Office
From: Doug Hewett <[e-mail]>
Sent: Thursday, September 15, 2022 3:01 PM
To: City Senior Management Team Email List <CitySeniorMa nagementTeam@ Fayetteville NC.gov>
Subject: Away from the Office
Good evening Team:
I will be away from the office until Thursday, September 22nd. While I'm away ACM Telly Whitfield is acting
City Manager and has complete signature authority in my absence. Telly's direct extension is 910-433-1459
and his cell number is 910-309-0284.
I can be reached via email and cell phone, but my response may be delayed.
As always, thanks for all you do.
Doug
*FAIYETTEV I LLE
AMERICA'S CAN 00 CITY
Douglas J. Hewett, ICMA-CM
City Manager
City Manager's Office
433 Hay Street I Fayetteville, NC 28301-5537
910-433-1990
[e-mail]
www.FayettevilleNC.gov
All communication, including this email, not specifically exempted by NC law is a public record and subject to release
upon request.
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