NCC221115_FRO Submitted_20220321

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. Hickory Grove (previously known as Glen at Cool Springs)
1. Project Name
2. Location of land -disturbing activity: County Lee City or Township Sanford
Highway/Street Cool Springs Road Latitude 35.493673 Longitude-79.236213
3. Approximate date land -disturbing activity will commence: Immediate
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 50
6. Amount of fee enclosed: $ N/A -previously approved The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Christian Sheppard E-mail Address [e-mail]
Telephone [phone] cell # Fax #
a
Landowner(s) of Record (attach accompanied page to list additional owners):
Taylor Morrison of Carolinas, Inc. [phone]
Telephone Fax Number
15501 Weston Parkway, Suite 100
Name
15501 Weston Parkway, Suite 100
Current Mailing Address
Cary NC
City
10. Deed Book No.
State
01663
Current Street Address
27513 Cary NC
Zip City
Page No. 0202
State
27513
Zip
Provide a copy of the most current deed.
Part B.
1. 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.
Taylor Morrison of Carolinas, Inc. [e-mail]
Name E-mail Address
15501 Weston Parkway, Suite 100 15501 Weston Parkway, Suite 100
Current Mailing Address Current Street Address
Cary NC 27513 Cary NC 27513
City State
Telephone [phone]
Zip City
Fax Number
State
Zip

2. (a) If the Financially Responsible Parry 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 State Zip
Telephone 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 State Zip
Telephone Fax Number
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.
Type or ri t name Title or Authority
I Z - ,
Signature Date
I.
a
, a Notary Public of the County of W .
State of North Carolina, hereby certify that C 4'A'4194appeared
personally before me this day and being duly sworn acknovjl6dged that the above form was
executed by him.
Witness %NOiNnotarial seal, this
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My commission expires 2-27-.23