NCC223358_FRO Submitted_20220927

FINANCIAL RESPONSIBILITWOWNERSHIP 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 and/
or fax information unavailable, place NIA in the blank.)
Part A. 11 th Street Apartments
1. Project Name p
2
3
Location of land -disturbing activity County Orange
Highway/Street S 11 th Street Latitude 36.0910
City or Township Mebane
____ Longitude-79.2580
Approximate date land -disturbing activity will commence: 9/26/22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.38
6. Amount of fee enclosed: $ 500 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes yes No Enclosed yes
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Danny Espitia E-mail Address [e-mail]
Telephone [phone] Cell # . VA. Fax # A/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Espitia Properties [phone] 41/4-
Name Telephone Fax Number
PO Box 13882 3200 Croasdaile Dr suite 302
Current Mailing Address Current Street Address
Durham, NC 27709 Durham, NC 27705
City State Zip City State Zip
10. Deed Book No. 6708 Page No.1354 Provide a copy of the most current deed.
Part B.
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 or firm is a sole proprietorship,
the name of the owner or manager maybe listed as the financially responsible party.
Espitia Properties [e-mail]
Name E-mail Address
PO Box 13882 3200 Croasdaile Dr suite 302
Current Mailing Address Current Street Address
Durham, NC 27709 Durham, NC 27705
City State
Telephone [phone]
Zip City
Fax Number 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:
AA_
Name
E-mail Address
Current Mailing Address
Current Street Address
City State Zip
City State Zip
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:
Esequiel Espitia
[e-mail]
Name of Registered Agent
E-mail Address
PO Box 13882
3200 Croasdaile Dr suite 302
Current Mailing Address
Current Street Address
Durham NC 27709
Durham NC 27705
City State Zip
City State Zip
Telephone [phone]
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.
Esequiel Espitia
Owner
Type or print ame Title or Authority
Sig Date
1,9calc1dO a Notary Public of the County of T)Uy ilayv�
State of North Carolina, hereby certify that r✓S:Cq W-b E—SY?1 it CA appeared
personally before me this day and being duly sworn acknow1bdged that the above form was
executed by him.
Witness my hand and notarial seal, this day of 20_9�_
Ok%ti 1 i i!/i�
AaA
A
Notary
o _ . �. can :
My commission expires u
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