NCC231797_FRO Submitted_20230614

NC STATE UNIVERSITY Finance and Administration
Action Sheet
Check one below: Date: 4/10/23
Letter/Memo
Originating Dept:_D&C
Contract/Agreement
Contact/Phone: 5-3064 _
Lease—New Renewal Other Associated Entity? Y/N
Easement X :_4/12/23_
UNC-SO
Reviewed/Signed off by/Date:
Reimbursement Budget Office*
X Other Legal* N/A
((�`
Subject: Integrative Science Building Other
NCDEQ Financial Responsibility Form AVC P✓ /
Notary* w(. .Ij.S
Signature(s) required: Charles A. Maimone—Vice Chancellor, Finance & Witness* N/A
Administration
Notary I X
Witness Vice Chancello oa,,,i2023
Final distribution by? Distribution requested as soon as possible! C��
'l *if required
Final version sent via: Mail n Electronically X
Background/Instructions: Project#: 202020005
All projects that disturb 0.1 acre (4,356 sq.ft.)or more of land area must have an approved Erosion and Sediment Control
Plan prior to commencement of land disturbing activity.A Financial Responsibility/Ownership (FRO) Form is required with
all applications for an Erosion and Sediment Control Plan Approval/Land Disturbing Permit from NCDEQ or the City of
Raleigh. This form establishes the legal liability for permit compliance and any associated violations and penalties, and
determines who will receive formal written correspondence from the issuing agency.
No Check is required from NCSU at this time.The designer will pay for the permit in order to expedite the process.
VC Comments:
Return to:
Budget and Resource Management, Box 7228 Human Resources, Box 7563
ATTN: Valerie Thompson ATTN: Rhonda Raynor
Campus Enterprises, Box 7291 RED, Box 7408
ATTN: ATTN: Danell Harrison
EH&PS, Box 8007 OGC, Box 7008
ATTN: Lillie Christiano ATTN: Katie Price
Facilities, Box 7232 X Design &Construction, Box 7520
ATTN: Sarah Kwon ATTN: Brandi Murray
Finance Division, Box 7010
ATTN:Tabitha Groelle
Doc ID:fb4b0c9648c6dd5e50060 aldale i

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 NC State Integrative Sciences Building (ISB)
2. Location of land-disturbing activity: County Wake City or Township Raleigh
Katherine Stinson Dr. 35.786659 LongRude decimal degrees) 78.670721
Highway/Street Latltude(decimal degrees) (
3. Approximate date land-disturbing activity will commence: May 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.67
6. Amount of fee enclosed $1 ,750.00 . 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 D Enclosed ❑x No D
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mark Collins E-mail Address [e-mail]
Phone: Office# 1 919 941 7900 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
State of North Carolina
Name Phone: Office# Mobile#
CAMPUS PO BOX 7008
Current Mailing Address Current Street Address
Raleigh NC 27695
City State Zip City State Zip
10. Deed Book No.000095 Page No. 00246 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).
North Carolina State University/ NCSU [e-mail]
Company Name E-mail Address
Campus Box 7201 Holladay Hall 106
Current Mailing Address Current Street Address
Raleigh, NC 27695-7201 Raleigh, NC 27695-7201
City State Zip City State Zip
Phone: Office# 919 515 2155 Mobile#
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) 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:
VHB [e-mail]
Engineering firm or other consultant E-mail Address
Charlie Townsend 919-741-5567
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 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.
Charles A. Maimone Vice Chancellor, Finance and Administration
Type-Qr print n e Title or Authority
17/l z3
Signature Date
I, 14Q(' (-(.1 A-. I O( , a Notary Public of the County of ■Va 1
Le--
•
State of North Carolina, hereby certify that WU/4a h. i�Gt prat 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 I day of ApiLi , 20 23
30,,m,
Notary
Margaret ADavis► �3 �� - a rya g
�YPusuC My commission expires
Wake County,NC
My Commission Expires Mandl 11,2028

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:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#