NCC230902_FRO Submitted_20230331

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 Environment and Natural Resources. (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.
Project Name Highway 56 Subdivision
Location of land -disturbing activity: County Franklin City or Township Franklinton
Highway/Street Highway 56 Latitude 36.1215 N Longitude 78.5111 W
Approximate date land -disturbing activity will commence: January 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11.2
6. Amount of fee enclosed: $ 780 . 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Steven Hayes E-mail Address [e-mail]
Telephone [phone] Cell # n/a Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Windsor Lakes LLC
Name Telephone Fax Number
28 Hayes Ct
Current Mailing Address Current Street Address
Franklinton NC 27525
City State
10. Deed Book No. 2224
Part B.
Zip City
Page No. 2172
State
Zip
Provide a copy of the most current deed.
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):
Windsor Lakes LLC [e-mail]
Name
28 Hayes Ct
E-mail Address
28 Hayes Ct
Current Mailing Address Current Street Address
Franklinton NC 27525 Franklinton NC 27525
City State
Telephone [phone]
Zip City
Fax Number n/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:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Typ r print name
Signature
Title or Authority
Date
I, " a). il n Il e,/ . a Notary Public of the County of \Ala kP_
State of North Carolina, hereby certify that _} ey6n _k'L es appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my haracLWd notarial seal, this q�+"
r
r 4o�aRy
eal V
pus",'
day of $40\teynLt,, r' 20 :;,u
Notary
My commission expires .3T) LOZ