NCC223516_FRO Submitted_20221013

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Apex Inspections & Permitting Building Project Name
2. Location of land -disturbing activity: County Wake City or Township Apex
Highway/Street322 N Mason St Latitude35.732820 Longitude-78.845452
3. Approximate date land -disturbing activity will commence: Spring/Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Governmental Services
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.56
6. Amount of fee enclosed: $130 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Daniel Edwards E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Apex 919-249-3353 919-249-3305
Name Telephone Fax Number
P.O Box 250 73 Hunter Street
Current Mailing Address Current Street Address
Apex NC 27502 Apex NC 27502
City State Zip City State Zip
10. Deed Book No. 01 7526 Page No. 01816-01819 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 may be listed as the financially responsible party.
Town of Apex [e-mail]
Name
P.O. Box 250
E-mail Address
73 Hunter Street
Current Mailing Address Current Street Address
Apex NC 27502 Apex NC 27502
City
State Zip City
State
Telephone [phone] Fax Number919-249-3305
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:
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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Town of Apex - Catherine Crosby
TypA o, print narpe
k
Town Manager
Title or iAu ooritty� .
Date
I, -:�-an 5CG Ilk s, Ue-"( , a Notary Public of the County of l vas
State of North Carolina, hereby certify that CcrWeA 1Yle C osW appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
_WN `
Witness my hand and notarial seal, this 95 day of QC_'s����
u0Cf 2002 i
Jontesca D Silver
Notary Public, Nash County, NO
My Commission Expires July 27, 2022
Seal
tary
My commission expires r:l�i a� a0