NCC220949_FRO Submitted_20220308

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 Environment and Natural Resources. (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 Villa Grande Phase Three
2. Location of land -disturbing activity: County Pitt City or Township Winterville
Highway/Street 2668 Red Forbes Road Latitude 35.529451 N _Longitude = 77.728553 W
3. Approximate date land -disturbing activity will commence: Late Winter 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16 acres
6. Amount of fee enclosed: $ 1,600.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee
is $450).
Has an erosion and sediment control plan been filed? Yes No Enclosed_X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bobby Billingsley E-mail Address BobbvBillingsley(a�ThomasEngineeringPA.com
Telephone [phone] Cell # 252.671.2408 Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Nolan Commercial Contractors, Inc. 910.219.4770 N/a
Name Telephone Fax Number
754 Ramsey Road, Suite F 754 Ramsey Road, Suite F
Current Mailing Address Current Street Address
Jacksonville, NC 28546 Jacksonville, NC 28546
City State Zip City State
WE
10. Deed Book No. 4231 Page No. 685 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Nolan Commercial Contractors, Inc. mindy(ftccihome.com
Name E-mail Address
754 Ramsey Road, Suite F 754 Ramsey Road, Suite F
Current Mailing Address Current Street Address
Jacksonville NC 28546 Jacksonville NC 28546
City State Zip City State Zip

Telephone [phone] Fax Number Nla
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Name of Registered Agent
E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Telephone
Fax Number
State Zip
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 by any change in the information provided herein.
Nolan4 . S des
Type o -pri ame
Signature
President, Nolan Commercial Contractors, Inc.
Title or Authority
Date
I, a Notary Public of the County of
....8100u"
State of North Carolina, hereby certify that 1 4i S S appeared
personally before me this day and being duly sworn ackno ledged that the above form was
executed by him.
++,,1111F1111//1j1 I .+.
Witness r MftDQojarial seal, this ! �0�ay of , 2Q L.
1 0
Notary
My commission expires
N' i,flrlllf 111+1IR4++,