NCC222115_FRO Submitted_20220607

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 address
or phone number is unavailable, place NIA in the blank.)
Part A.
Project Name Currin Hill Subdivision, Phase I - Lots 7, 10, 11, 14, 22, 23 & 38-40
2. Location of land -disturbing activity: County Cumberland City or Township Carvers Creek Township
Highway/Street Nairn Street Latitude(debmal degrees) N 35.1985' Long ltude(decimal degrees) W-78.8670"
3. Approximate date land -disturbing activity will commence: Aril 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc ): Residential
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.31 acres
6. Amount of fee enclosed: $ 500.00 . The application fee of $100.00 per acre (rounded up
to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ
7. Has an erosion and sediment control plan been filed? Yes LL Enclosed J No L
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chris Sherrod E-mail Address- [e-mail] _
Phone: Office # 910-892-9299 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
ABJ Investments, LLC
Name
P.O. Box 361
Current Mailing Address
910-483-1861
Phone: Office # Mobile #
2031 Middle Road
Current Street Address
Fayetteville NC 28302 Eastover NC 28312
City State Zip City State Zip
Lots 7, 10, 11,14, 39 & 40
10. Deed Book No. 10825 Page No. 027 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).
Signature Home Builders. Inc. csherrod.shb(aDgmail.com
Company Name E-mail Address
1209 N. Main Street Same
Current Mailing Address Current Street Address
Lllington N.C. 27546 Same
City State Zip City State Zip
Phone: Office # 910-892-9299 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:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City
Mobile #
State Zip
Name of Individual to Contact (if Registered Agent is a company)

Continued from Items 9 & 90 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:
Signature Home Builders, Inc 910-892-9299 910-985-1136
Name Phone: Office # Mobile #
1209 N. Main Street Same
Current Mailing Address Current Street Address
Lillin ton N.C. 27546 Same
City State Zip City State Zip
Lots 22, 23 & 38 Lots 22, 23 & 38
Deed Book No. 11384 Page No. 005 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Current Mailing Address
City State
Deed Book No.
Landowner 4 of Record:
Name
Current Mailing Address
City State
Deed Book No.
Landowner 5 of Record:
Name
Current Mailing Address
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office #
Current Street Address
Mobile #
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

(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
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.
William L. Daughtry
Type or print name
Signature
Owner/President
Title or Authority
Date
a Notary Public of the County of JQrr-ti spn
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged at the above form was
executed by him/her.
Witness my hand and notarial seal, this J"AA.' day of G 20 --
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