NCC224223_FRO Submitted_20230109

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. Winchester Drive Extension
1. Project Name
2. Location of land -disturbing activity: CountyWake City or TownshipRalelgh
Highway/Street Winchester Drive Latitude35.87835 Longitude-78•73623
3. Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Roadway & Ped
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.45 Ae
6. Amount of fee enclosed: $ 200 . 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 No Enclosedx
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameBrian Roth-Roffy, PE E-mail Address [e-mail]
Telephone[phone] cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Raleigh
Name Telephone Fax Number
PO Box 590 222 W Hargett St
Current Mailing Address Current Street Address
Raleigh, NC 27602 Raleigh, NC 27601
City State Zip City State Zip
10. Deed Book No. 1 996/2006 Page No. 1 821 /875 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.
City of Raleigh [e-mail]
Name E-mail Address
PO Box 590 222 W Hargett St
Current Mailing Address Current Street Address
Raleigh, NC 27602 Raleigh, NC 27601
City State Zip City State Zip
Telephone Fax Fax NumberN/A

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
City State Zip
Telephone
Current Street Address
City
Fax Number
State Zip
(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:
Marchell Adams -David - City Manager
Name of Registered Agent
PO Box 590
Current Mailing Address
Raleigh, NC 27602
[e-mail]
E-mail Address
222 W Hargett St
Current Street Address
Raleigh, NC 27601
City State Zip City State Zip
Telephone[phone] Fax Number N/A
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.
Rich d L. Kelly, P.E.
yp or r t me
Signature
Engineering Services Director
Title or Authority
�---
Date
I, ViAn t amD6ni- 41 'WCY, a Notary Public of the County of We,
State of North Carolina, hereby certify that t 61 r L - V) appeared
personally before me this day and being duly sworn acknowledged that t e above form was
executed by him.
Witness my hand and notarial sea[, this
GPM 1„111.. L,O�i
4 Cm Exp. A
9`Ie41022
,~�1111111111~•
CovN'�,,,
1 vl day of 20 2�;k
YlUIA-)—tbA'Ie��
My commission expires �1 -

Winchester Drive Extension Project
Landowner(s) of Record
PIN
Real Estate ID
Owner
Deed Rook
Deed Page
Deed Date
777850015
214099
Frank R Anderson Realty & Investment
6455
129
3/2/1995
777843910
6293
HAB Properties LLC
14160
332
11/17/2010
777845757
9997
JRYLLC
13275
1126
10/16/2008