NCC215489_FRO Submitted_20211005

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. (Please type or print and, if the question is
not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name: Sandy Neck Subdivision
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street SR1400 (Cliffdale Rd) Latitude 35.059115' Longitude-79.050359'
3. Approximate date land -disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.3
6. Amount of flee enclosed: $910.00 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 $585.00).
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 Matthew Alfonso E-mail Address [e-mail]
Telephone None Cell # [phone] Fax # None
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Sandy Neck BFR, LLC [phone] None
Name Telephone Fax Number
405 Washington Street Same
Current Mailing Address Current Street Address
Duxbury, MA 02332
City State Zip City State Zip
10. Deed Book No. 11120 Page No. 0512 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 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.
Sandy Neck BFR, LLC [e-mail]
Name (Matthew Alfonso) E-mail Address
4 Noel Henry Drive Same
Current Mailing Address Current Street Address
East Sandwich, MA 02537
City State Zip
Telephone # [phone]
City
Fax #
None
State Zip

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 I D# 2691 E-mail Address
;Fg36 U ti %d- e '200 7g901 z-&
Current Mailing Ad ess Current Street Addfess
0 NC.._ 276P`7
City State Zip -
Telephone # /- �/$7- J�, C,
City (/ State Zip
Fax #
(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. -
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone # Fax #
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.
1 l� �3 ( '0 /R(- a V) i
Type or print nafne Title or Othority
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Signature Date
a Notary Public of the County of r a -
State of North Carolina, hereby certify that iX_� t_U 0-1 jr2rSo 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 3Q day I>-"7t 2021.
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