NCC223328_FRO Submitted_20220922

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 address or phone
number is unavailable, place NIA in the blank.)
Part A. Qk CgMLSS LArJE S�
1. Project Name
2. Location of land -disturbing activity: CountvChatham City or TownshipGoldston
HighwaylStreetCypress Ln _ Latltuftdacimaldegraes) 35.5944�Longitude(dimaidegrae5)-79.3309
3. Approximate date land -disturbing activity will commence: 9/15/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Ref sidential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.40
6. Amount of fee enclosed: $200.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes Ej Enclosed ❑ No ❑
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJosh Brooks E-mail [e-mail]
Phone: Office # [phone] Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Thomas R. Kirk, II [phone]
Name Phone: Office # Mobile #
P.O. Box 368 53 Crecent Ave.
Current Mailing Address Current Street Address
Goldston NC 27252 Goldston NC 27207
City State Zip City State Zip
10. Deed Book No.21 37 Page No.0526 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole propnotorship or if the landowner(s) is
an iodividual(s), the name(s) of the owner(s) may be listed as the financially responsible pady(ies).
JB Builders, LLC
Company Name
1880 Zeb Brooks Rd.
[e-mail]
E-mail Address
1880 Zeb Brooks Rd.
Current Mailing Address Current Street Address
Bear Creek NC 27207 Bear Creek NC 27207
City State Zip City State Zip
Phone: Office # [phone] Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent.
Josh Brooks [e-mail]
Name of Registered Agent E-mail Address
1880 Zeb Brooks Rd. 1880 Zeb Brooks Rd.
Current Mailing Address Current Street Address
Bear Creek NC 27207 Bear Creek NC 27207
City State Zip City State Zip
Phone: Office # [phone] Mobile #
Josh Brooks
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
l

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Parry). I agree to provide
corrected information should there be any change in the information provided herein.
Josh Brooks
2011SP—Ame
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Owner
Title or Authority
9/15/20
Date
I, , c& l a Notary Public of the County of (' he-- �
State of North Carolina, hereby certify that ,inclfl Q D1:!, LL appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this _JIA_day of 20-Qa
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