NCC240970_FRO Submitted_20240404

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 Cape Carteret MUP
*If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Carteret City or Township City
US 58/Taylor Notion Road 34.697046 -77.069302
Highway/Street Latitude(decimal degrees) Longitude(decimaldegrees)
3. Approximate date land-disturbing activity will commence: 2/1/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Recreational
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.65
6. Amount of fee enclosed: $500 . 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 ❑ Enclosed 0 No D
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Frank Rush E-mail Address [e-mail]
Phone: Office# 252-393-8483 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MHE Enterprises LLC N/A N/A
Name Phone: Office# Mobile#
106 Manatee Street N/A
Current Mailing Address Current Street Address
Cape Carteret, NC 28584 N/A
City State Zip City State Zip
10. Deed Book No. 1771 Page No. 099 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)maybe listed as the financially responsible party(ies).
Town of Cape Carteret [e-mail]
Company Name E-mail Address
102 Dolphin Street 102 Dolphin Street
Current Mailing Address Current Street Address
Cape Carteret, NC 28584 Cape Carteret, NC 28584
City State Zip City State Zip
Phone: Office# 252-393-8483 Mobile#N/A
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:
Frank Rush [e-mail]
Name of Registered Agent E-mail Address
102 Dolphin Street 102 Dolphin Street
Current Mailing Address Current Street Address
Cape Carteret, NC 28584 Cape Carteret, NC 28584
City State Zip City State Zip
Phone: Office# 252-393-8483 Mobile# N/A
N/A
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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.
N/A
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.
Frank Rush Town Manager
Type or print name Title or Authority
Signature Date
DD
eC eY Lt°"f lYl(��l?� ( , a Notary Public of the County of C V�cv t✓±
State of North Carolina, hereby certify that —Yank.- c_.LSC 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 day of Janvsti1 , 20 2i
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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:
United States of America 252-728-3793 N/A
Name Phone: Office# Mobile#
2721 Highway 101 N/A
Current Mailing Address Current Street Address
Beaufort, NC 28516 N/A
City State Zip City State Zip
Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
Landowner 3 of Record:
Holland Homes, LLC N/A N/A
Name Phone: Office# Mobile#
105 Page Place 112 Taylor Notion Rd
Current Mailing Address Current Street Address
Emerald Isle, NC 28594 Cape Carteret, NC 28584
City State Zip City State Zip
Deed Book No. 1504 Page No.014 Provide a copy of the most current deed.
Landowner 4 of Record:
Terri Tysinger Ashby N/A N/A
Name Phone: Office# Mobile#
109 Dolphin St 110 Taylor Notion Rd
Current Mailing Address Current Street Address
Cape Carteret, NC 28584 Cape Carteret, NC 28584
City State Zip City State Zip
Deed Book No. 1788 Page No.036 Provide a copy of the most current deed.
Landowner 5 of Record:
Town of Cape Carteret 252-393-8483 N/A
Name Phone: Office# Mobile#
102 Dolphin Street 100 Taylor Notion Rd
Current Mailing Address Current Street Address
Cape Carteret, NC 28584 Cape Carteret, NC 28584
City State Zip City State Zip
Deed Book No.34 Page No.798 Provide a copy of the most current deed.

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 6 of Record:
Nancy B. Mallard N/A N/A
Name Phone: Office# Mobile#
126 Taylor Notion Road 126 Taylor Notion Road
Current Mailing Address Current Street Address
Cape Carteret, NC 28584 Cape Carteret, NC 28584
City State Zip City State Zip
Deed Book No.967 Page No. 179 Provide a copy of the most current deed.
Landowner 7 of Record:
Shelby W. Brown N/A N/A
Name Phone: Office# Mobile#
130 Taylor Notion Road 130 Taylor Notion Road
Current Mailing Address Current Street Address
Cape Carteret, NC 28584 Cape Carteret, NC 28584
City State Zip City State Zip
Deed Book No.580 Page No.213 Provide a copy of the most current deed.
Landowner 8 of Record:
George D. Newton N/A N/A
Name Phone: Office# Mobile#
134 Taylor Notion Road 134 Taylor Notion Road
Current Mailing Address Current Street Address
Cape Carteret, NC 28584 Cape Carteret, NC 28584
City State Zip City State Zip
Deed Book No. 1099 Page No.486 Provide a copy of the most current deed.
Landowner 9 of Record:
Wesley A. Morrison N/A N/A
Name Phone: Office# Mobile#
136 Taylor Notion Road 136 Taylor Notion Road
Current Mailing Address Current Street Address
Cape Carteret, NC 28584 Cape Carteret, NC 28584
City State Zip City State Zip
Deed Book No.0385 Page No.236 Provide a copy of the most current deed.

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 10 of Record:
Randy Witkowski N/A N/A
Name Phone: Office# Mobile#
413 Ardan Oaks Circle 413 Ardan Oaks Circle
Current Mailing Address Current Street Address
Cape Carteret, NC 28584 Cape Carteret, NC 28584
City State Zip City State Zip
Deed Book No. 1773 Page No. 103 Provide a copy of the most current deed.
Landowner 11 of Record:
Ronald Springfield N/A N/A
Name Phone: Office# Mobile#
190 Barrington Ridge 406 Ardan Oaks Circle
Current Mailing Address Current Street Address
Bogue, NC 28570 Cape Carteret, NC 28584
City State Zip City State Zip
Deed Book No. 1626 Page No.61 Provide a copy of the most current deed.
Landowner 12 of Record:
Minh Le N/A N/A
Name Phone: Office# Mobile#
8700 Emerald Dr Unit #2 404 Ardan Oaks Circle
Current Mailing Address Current Street Address
Emerald Isle, NC 7007 28594 Cape Carteret, NC 28584
City State Zip City State Zip
Deed Book No. 1653 Page No. 105 Provide a copy of the most current deed.
Landowner 13 of Record:
Lionel Pelletier, Ill N/A N/A
Name Phone: Office# Mobile#
148 Taylor Notion Road 148 Taylor Notion Road
Current Mailing Address Current Street Address
Cape Carteret, NC 28584 Cape Carteret, NC 28584
City State Zip City State Zip
Deed Book No.516 Page No.233 Provide a copy of the most current deed.

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 14 of Record:
Ardan Oaks Homeowners Association N/A N/A
Name Phone: Office# Mobile#
104 Clubhouse Dr N/A
Current Mailing Address Current Street Address
Cape Carteret, NC 28584 N/A
City State Zip City State Zip
Deed Book No. 1 135 Page No. 187 Provide a copy of the most current deed.
Landowner 15 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 16 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 17 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 I 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#