NCC222783_FRO Submitted_20220816

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.
1. Project Name: Clayton Homes Sales Center
2. Location of land -disturbing activity: County: Pender City or Township: Topsail
Highway/Street Off of Hwy 17 inside Waterford master development
Latitude: 34' 25' 18" N Longitude: 77' 38' 33"W
3. Approximate date land -disturbing activity will commence: October 15 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.46 Ac
6. Amount of fee enclosed: $1500 (Express) & $390 (Acres). 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jeff Foster
E-mail Address: Jeff. Fosteraclaytonhomes.com
Telephone: [phone] Fax#: [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CMH Homes, Inc. _704-756-9191
Name Telephone Fax Number
5000 Clayton Road Same as Mailinq Address
Current Mailing Address Current Street Address
Maryville Tn 37804
City State Zip City
State
10. Deed Book No. 4724 Page No.463-466 Provide a copy of the most current deed.
Part B.
Zip
1. 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):
CMH Homes, Inc ieff.foster(a)claytonhomes.com
Name E-mail Address
5000 Clayton Road Same as Mailing Address
Current Mailing Address Current Street Address
Maryville TN 37804
City State Zip City 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
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 Manager
Current Mailing Address
City State Zip
Telephone:
E-mail Address
Current Street Address
City State Zip
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.
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a Notary Public of the County of 10 unT
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personally before me this day and being duly sw6rn acknowledged that the above form was
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