NCC230387_FRO Submitted_20230213

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 N/A in the blank.)
Part A.
1. Project NameWlllow Bend Subdivision Ph 2 - Lots 29,30,31,32,33,34
2. Location of land -disturbing activity: County Franklin city or TownshipYOUngsville
3
Willow Bend Drive 3G,GF33131V
Highway/Street Latltude(decimal degrees) LOngltude(decimal degrees)
Approximate date land -disturbing activity will commence: November 2022
78.536280 W
4. Purpose of development (residential, commercial, industrial, institutional, etc.) _Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.79 ae
6. Amount of fee enclosed $1,050 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 $250 per acre up to eight acres, after which 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David Edwards
E-mail Address [e-mail]
Phone: Office # 919-556-4700
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Willow Development, LLC
n/a n/a
Name
Phone: Office # Mobile #
n/a
Current Mailing Address
Current Street Address
n/a n/a n/a
City State Zip
City State Zip
10. Deed Book No. 2274 Page No.
1658-1659 Provide a copy of the most current deed.

Part B.
1. Company(ies) 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 proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Winslow Grand. LLC
%,ullyany rvarne
PO BOX 610
Current Mailing Address
Youngsville NC 27596
City State Zip
Phone: Office # 919-556-4700
[e-mail]
E-mail Address
140 East Main Street
Current Street Address
Same
City State Zip
Mobile # n/a
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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 other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) It 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:
FLM Engineering, Inc
Engineering firm or other consultant
Christopher Lewis, PE
Individual contact person (type or print)
dewis [e-mail]
E-mail Address
919-610-1051 919-802-7146
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.
/ 6
Type or print name
ature
Title or Auth ity
I I I
Date
1, rL j a Notary Public of the County of rm1y'u A3
State of North Carolina, hereby certify that kkf� Q A')F,/ -0 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 2� day of
TERESA C SMITH
NOTARY PUBLIC
FRAINK�tN COUNTY
STATE OF NORTH CAROLINA
�Nw
20
Lua_A�j �f
Notary
My commission expires 11-0 .

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Winslow Custom Homes
n/a n/a
Name
Phone: Office # Mobile #
PO Box 610
n/a
Current Mailing Address
Current Street Address
Youngsville NC 27596
n/a
City State Zip
City State Zip
Deed Book No. 2313 Page No
78-79 Provide a copy of the most current deed.
Landowner 3 of Record
Rhea and Zachary Coyle
n/a n/a
Name
Phone: Office # Mobile #
106 Willow Pond Dr
n/a
Current Mailing Address
Current Street Address
La Grange NC 28551
n/a
City State Zip
City State Zip
2302
1998 1999
Deed Book No Page No.
Provide a copy of the most current deed
Landowner 4 of Record:
Marc and Melissa Williamson n/a n/a
Name Phone: Office # Mobile #
1636 Ripley Woods St n/a
Current Mailing Address Current Street Address
Wake Forest NC 27587 n/a
City State
Deed Book No. 2313
Landowner 5 of Record
Zip City State Zip
Page No. 11 14-1 115 Provide a copy of the most current deed.
Samuel and Jean Miles n/a n/a
Name Phone: Office # Mobile #
15 Hamilton Way n/a
Current Mailing Address Current Street Address
Youngsville NC 27596 n/a
City State Zip City State Zip
Deed Book No. 2315 Page No 1567-1568 Provide a copy of the most current deed