NCC231072_FRO Submitted_20230417

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 Name The Station at Northview
2. Location of land-disturbing activity: County Lee City or Township Sanford
Charleston Drive 35.517792 -79.183944
Highway/Street Latitude�aa��maide9�eas� Long itude(aacimaidegrees)
3. Approximate date land-disturbing activity will commence:April 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 26.5
6. Amount of fee enclosed $4,700.00 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name
Corey us E-mail Address Mab [e-mail]
Phone: Office# 919-776-4641 Mobile# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Keller Investment, LLC 919-776-4641 910-728-5714
Name Phone: Office# Mobile#
1600 Colon Road 1600 Colon Road
Current Mailing Address Current Street Address
_Sanford, NC 27330 Sanford, NC 27330
City State Zip City State Zip
10. Deed Book No. 1658 Page No.550 Provide a copy of the most current deed.
Deed Book No. 1665 Page No. 398
Deed Book No. 1703 Page No.290

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 orif the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Carolina Commercial Contractors, LLC [e-mail]
Company Name E-mail Address
1600 Colon Road 1600 Colon Road
Current Mailing Address Current Street Address
Sanford, NC 27330 Sanford, NC 27330
City State Zip City State Zip
Phone: Office# 919-776-4641 Mobile# [phone]
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:
ame 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) If 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:
CE Group, Inc. [e-mail]
Engineering firm or other consultant E-mail Address
Joe Faulkner 919-606-7703 919-606-7703
Individual contact person (type or print) 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 regikered 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.
William Carter Keller Manager
Type or print narrq Title or Authority
Signature Date
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,M 04)1 �. �G ( , a Notary Public of the County of we-
State of North Carolina, hereby certify that Al;1 lianr Co.ridr Koo lc r 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 94 day of /A AY'll , 20 S
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Q-; TA 0- Notary
_Seal _ My commission expires 2 H "r �v� 17
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