NCC232449_FRO Submitted_20230815

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 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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name Sidewalk Improvement Project(Spring Forest, Millbrook, and New Hope Rd)
2. Location of land-disturbing activity: County Wake City or Township Raleigh
Highway/Street see Part A-1 Latitude 35.8063 deg. N Longitude 78.6140 deg. W
3. Approximate date land-disturbing activity will commence: July 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):City Sidewalk Project
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.35
6. Amount of fee enclosed: $ 282.75 . 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 X Enclosed_ X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jaykumar Shah E-mail Address: jaykumar.shaht 2raleighnc.gov
Telephone [phone] Cell# 224-200-6889 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Raleigh (Public Right-of-Wayl 919-996-3030 919-996-7168
Name Telephone Fax Number
222 W. Hargett Street
Current Mailing Address Current Street Address
Raleigh NC 27602
City State Zip City State Zip
10. Deed Book No. * Page No. * Provide a copy of the most current deed.
*Please note that the City of Raleigh will be acquiring temporary and permanent
easements in order to construct project. Copies of the recorded deeds and/or plat will be
provided to beginning construction.
Part B.

1. Company (ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Richard Kelly [e-mail]
Name E-mail Address
222 West Hargett Street
Current Mailing Address Current Street Address
Raleigh NC 27601
City State Zip City State Zip
Telephone Fax Number
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Marchell Adams-David
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Type a print Mir"' Title or Authority
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ature Date /
I, V idct U3 -%pbd1- © t rVC-r, a Notary Public of the County of \Ai C,
State of North Carolina, hereby certify that PILhIIId ' 16e-1 1 1 appeared
personally before me this dayand beingdulysworn acknowledged that the abov form was executed
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by him. !!.. `
Witness my hand and notarial seal, this `��day of J U r)C- , 20 cry ?1
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