NCC222114_FRO Submitted_20220607

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. Calico
1. Project Name
2. Location of land -disturbing activity: County Carteret
Highway/Street SR1176 Latitud
34°44'48"
3. Approximate date land -disturbing activity will commence
_ City or Township Morehead City
Longitude 76043'43"
April 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 36.99
6. Amount of fee enclosed: $ N/A (transfer) 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 Bert Exum E-mail Address [e-mail]
Telephone Cell # 910-540-9716 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Calico Area Developers, LLC 336-282-3535
Name Telephone Fax Number
5603 New Garden Village Drive
Current Mailing Address Current Street Address
Greensboro, NC 27410
City State Zip City State Zip
10. Deed Book No. 1737 Page No. 108 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.
Calico Area Developers, LLC [e-mail]
Name E-mail Address
5603 New Garden Village Drive
Current Mailing Address Current Street Address
Greensboro, NC 27410
City State Zip City State Zip
Telephone,
336-282-3535 Fax Number

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
(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
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 be any change in the information provided herein.
Thomas C. Hall
Type r print name
Signature
Calico Area Developers, LLC - Manager
Title or Authority
� - 3
Date
I, a Notary Public of the County of ZC1UOJ30_4T)
State of North Carolina, hereby certify that _FVyw C Rau 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 `3
WENDY B PAYNE
Notary Public, North Carolina
Seal Rockingham County
My Commission Expires
day of , 20 ��—
Notary
My commission expires����
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