NCC220847_FRO Submitted_20220222

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.
Project Name: _Kamdon Ranch — EC Plan for Lots 15, 16, and 70 - 74
2. Location of land -disturbing activity: County: Johnston City or Township: Hectors Creek
Highway/Street: Olive Branch and Retreat Run Latitude: 35.5236 Longitude: - 78.4092
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.5 acres
6. Amount of fee enclosed: $260.00 + $140.00 The application fee of $100.00 per acre (rounded up to
the next acre) is assessed without a ceiling amount. (Example: an 8.2-acre application fee is $900).
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: Scott Lee E-mail Address: laura(d)scottleehomes.com
Telephone: [phone] Cell: [phone] Fax: (919)
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Scott Lee Homes, Inc.
Name
104 State Avenue, Suite 103
Current Mailing Address
Clayton NC 27520
City State Zip
[phone] _
Telephone Fax
104 State Avenue, Suite 103
Current Street Address
Clayton NC 27520
City State Zip
10. Deed Book No.: 5804 Page No.: 326 — 328 Provide a copy of the most current deed.
6055 212 - 213
Part B.
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.
Scott Lee Homes, Inc.
Name
104 State Avenue. Suite 103
Current Mailing Address
Clayton NC 27520
City State Zip
Telephone: [phone]
Iaura(@scottleehomes.com
E-mail Address
104 State Avenue, Suite 103
Current Street Address
Clayton NC 27520
City State Zip
Fax (919)

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
Telephone Fax Number
State Zip
(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:
Laura S. Lee
Name of Registered Agent
104 State Avenue, Suite 103
Current Mailing Address
Clayton NC 27520
City State Zip
Telephone [phone]
laura(c).scottleehomes.com
E-mail Address
104 State Avenue, Suite 103
Current Street Address
Clayton NC 27520
City State Zip
Fax Number (919)
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.
P. Scott Lee President, Scott Lee Homes, Inc.
Type int name Title or Authority
Signature Date
1 -, �—
a Notary Public of the County of �� 0 —
State of North Carolina, hereby certify that ? ' Cne f/ La-, appeared
77
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 El day of'�QC������ 2021
Chacona Leach
NOTARY PUBLIC
SeVjpke County, NC
My Commission Expires August 04, 2025
Notary`
My commission expires / Z. ��