NCC223417_FRO Submitted_20221007

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.
Project Name Intersect East Historic Properties
2. Location of land -disturbing activity: County Pitt I City or Township Greenv
3. Highway/Street 1020 Clark St, 400 W 11th St, 1000 S Green St
Latitude 34042'54.7"N Longitude 76°59'6.6"W
4. Approximate date land -disturbing activity will commence: 10/1/22
5. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial/Commercial
6. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.3
7. Amount of fee enclosed: $ 300.00 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).
8. Has an erosion and sediment control plan been filed? Yes No Enclosed X
9. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Evan Morville E-mail Address [e-mail]
Telephone [phone] Cell # 410-598-1762 Fax #
10. Landowner(s) of Record (attach accompanied page to list additional owners):
Intersect East Historic Properties, LLC 443-391-8420
Name Telephone
909 Ridgebrook Road, Ste 216
Current Mailing Address
Sparks, MD 21152
City State Zip
Current Street Address
City
State
Fax Number
Zip
11. Deed Book No. DB 4149 Page No. PG 348 Provide a copy of the most current deed.
Part B.
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):
Intersect East Historic Properties. LLC
Name
909 Ridgebrook Rd, Ste 216
Current Mailing Address
Sparks, MD 21152
City State Zip
Telephone [phone]
E-mail Address
Current Street Address
City State
Fax Number
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
tZalA/C PC
City State Zip City State Zip
Telephone t9 - M'-
e3(00
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:
N/A
Name of Registered Agent
Current Mailing Address
�!l
Telephone
E-mail Address
Current Street Address
State Zip 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 by any change in the information provided herein.
Type rint e Title or Authority
Sign- e Date ur
a Notary Public of the County of _8CU[+(n0✓�2
Mu-J la��� t✓u�nezr�
State of Nafflig-6aro i , hereby certify that t3v- ct v► 2oc-f .' 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
SARA J BARNETT
CRY PUBLIC
BALTIMORE COUNTY
MARYLAND
l � -day of /bi W+ 20o?
Notary
My commission expires 120 Z 3