NCC230134_FRO Submitted_20230118

TOWN OF KNIGHTDALE 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 Town
:,. of Knightdale Unified Development Ordinance before this form and an acceptable
` erosion and sedimentation control plan have been completed and approved by Town of
Knightdale, Public Works Department, Stormwater Division. (Please type or print and, if the
question is not applicable, place N/A in the blank.)
Part A.
1. Project Name Elevate Riverview Knightdale
2. Location of land -disturbing activity: ETJ (Town Limits or ETJ)
Highway/Street Hodge & Poole Rd Latitude 35.756023 Longitude -78.521439
3. Approximate date land -disturbing activity will commence: 1 /30/2023
4. Type of development (residential, commercial, industrial, institutional, etc.): Apartment
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 28.6 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brad Chambers
E-mail Address [e-mail]
336-403-8822
Phone # cell
#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Signature Hodge Road, LLC
336-294-9199 CTaylor@SlgraturePropertyGroup.00m
Name(s)
Telephone E-mail address
530 Eugene Ct.
Same
Current Mailing Address
Current Street Address
Greensboro NC 27401
Same
City State Zip
City State Zip
8. Deed Book No. 19209 Page No. 491 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Signature Hodge Road, LLC
[e-mail]
Name
E-mail Address
530 Eugene Ct
Same
Current Mailing Address
Current Street Address
Greensboro NC 27401
Same
City State Zip
City State Zip
Phone # [phone]

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Town of Knightdale Erosion and Sedimentation Control Ordinance and/or
Land Disturbance Permit:
Joe Faulkner, PLA [e-mail]
Name E-mail Address
301 Glenwood Avenue Suite 220 Same
Current Mailing Address Current Street Address
Raleigh NC 27603 Same
City State Zip City State Zip
Phone # [phone]
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone #
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.
Si tur odge Road, LLC
Ty e t nam
S ature
Craig Taylor, Vice President
Title or Authority
Date
I, Z�D2 t 1LA LAa OLsoh , a Notary Public of the County of UkL 1= .'A
State of North Carolina, hereby certify that Cra-i e. A. T" LvA2 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 5day of U-p, 20Q_-AZ� I k 1�"_
sal
ka K. Larson Notary
NOTARY PUBLIC My commission expires
Davidson County, NO
My Commission Expires April 06, 2026