NCC220692_FRO Submitted_20220209

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. Prince Place Lots 7,8,9,10,11
1. Project Name
2. Location of land -disturbing activity: County Harnett City or Township Hectors Creek
Highway/Street Prince Place Dr Latitude 35.500733 Longitude-78.876342
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.39
6. Amount of fee enclosed: $ 260.00 . 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 Josh Clowes E-mail Address [e-mail]
Telephone N/A Cell # 919-609-6340 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Davidson Homes, LLC 919-376-6869 N/A
Name Telephone Fax Number
336 James Record Road 336 James Record Road
Current Mailing Address Current Street Address
Huntsville AL 35824 Huntsville AL 35824
City
10. Deed Book No. 2021
State
Zip City
Page No. 372
State
Zip
Provide a copy of the most current deed.
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.
Davidson Homes, LLC (Brad Nelson) [e-mail]
Name
117 Centrewest Court
Current Mailing Address
Cary NC 27513
City State Zip
Telephone [phone]
E-mail Address
117 Centrewest Court
Current Street Address
Cary NC 27513
City State Zip
Fax Number N/A

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:
Registered Agent Solutions
Name of Registered Agent E-mail Address
17 Mine Lake Court, Ste. 100 17 Mine Lake Court, Ste. 100
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number
DAVIDSON ACCOUNT: D1085496
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.
Brad Nelson Raleigh Division President
Type or print name
R'4�__Lo�
Signature
Title or Authority
1 1 123 i.2-1
Date
I, � S c A V q , a Notary Public of the County of U,-) q Ic C_
State of North Carolina, hereby certify that ��n :::' �4 -)w;Z y '7\J ':�i Cc)-,N appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 2 K day of 202- j
RITU SUKHIIJA
NOTA&ga�LI� NORTH CAROLINA
WAKE COUNTY
MY COMMISSION EXPIRES NOV 12, 2023
Notary
My commission expires 7\1I0\i► z Z Z 2