NCC222674_FRO Submitted_20220726

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. 1. Project Name.Cuthbertson Road Townhomes
2.
Location of land -disturbing activity: County Union
City or Township Sandy Ridge
Highway/Street CBthbertson Road Latitude_34.95861 Longitude—80.75000�
3. Approximate date land -disturbing activity will commence: May 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.); Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_ 16.12
6. Amount of fee enclosed: $1,105 paid 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).
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 Kilby E-mail [e-mail]
Telephone [phone] Cell # 704-905-1831 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Classic Neighborhood Development LLC
Name Telephone Fax Number
1111 N Post Oak Rd
Current Mailing Address Current Street Address
Houston, TX
City State Zip City State Zip
10. Deed Book No. 7973 Page No. 0270 Provide a copy of the most current deed
1. �ompany(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
Part comprehensive list of all responsible parties on an attached sheet.) If the company orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Classic Neighborhood Development, LLC [e-mail]
Name E-mail Address
1111 North Post Oak Road
Current Mailing Address Current Street Address
Houston TX 77055
City
State Zip City
Telephone Fax Number
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
Current Mailing Address
City State
Teleph
E-mail Address
Current Street Address
Zip City
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:
Corporation Service Company [e-mail]
Name of Registered Agent
2626 Glenwood Ave., Suite 550
Current Mailing Address
Raliegh NC 27608
City State Zip
Telephone [phone]
E-mail Address
Current Street Address
City
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 be any change in the information provided herein.
Area Land Manager _
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Signature Date 1 1
I, _r, � E a Notary Public of the County of _%Unka bLf�L4�
State of North Carolina, hereby certify that _4 Ge,4_K./iyl_ b appeared
personally before me this day and being duly sworn acknowledged that7t a bove form was
executed by him.
Witness my hand and notarial seal, this 0?2_day of
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