NCC230758_FRO Submitted_20230321

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.
1. Project Nam
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3.
4.
5.
6.
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Waterleig h Phase 2 Conservation Subdivision (C�
Location of land disturbing activity: County Currltuck City or Township Moyock
Tulls Creek Rd 36,52267 76.14336
HighwaylStreet Lat�tude(decimal degrees? LOngltude(decimal degrees)
Approximate date land -disturbing activity will commence: August 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.65 Acres
Amount of fee enclosed: $ 800.00 . 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.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed x❑ No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Terry Drew E-mail Address [e-mail]
Phone: Office # 7576718700 Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Waterleigh NC, LLC 7574635000
Name Phone: Office #
448 Viking Dr. Ste 220 same as mailing
Current Mailing Address
Virginia Beach VA 23452
Current Street Address
nla
Mobile #
City State Zip City State Zip
10. Deed Book No. 1705 Page No. 243 Provide a copy of the most current deed.
1 � @ T 0 T �
DEC 302022 IU

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 proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Chesapeake Homes of North Carolina., A( ,
Company Name E-mail Address
448 Viking Dr. Ste 220 same as mailing
Current Mailing Address Current Street Address
Virginia Beach VA 23452
City State
Phone: Office # 7576718700
Zip City
Mobile #
State
Zip
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:
Name of Registered Agent E-mail AddressIN
nEC 3
Current Mailing Address Current Street Address B
y
City State Zip City State
Phone: Office # Mobile #
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:
CT Corporation System
Name of Registered Agent E-mail Address
160 Mine Lake Ct. Ste 200 same as mailing
Current Mailing Address
Raleigh NC 27615-6417
City State Zip
Prone: Office #
Current Street Address
City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Raymond Gottlieb
Type or print namef
i
Signature
Manager
Title or Authority
Date
I, �• S � a Notary Public of the County of HNC•{ &e'ct,
V l �5i nfG.. r
State of Alar4-Qa;Q4�a, hereby certify that ►k� L , (;rfv,6' � 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 cxn day of 20aa
ECynthia G. Shank
Notary Public
REG. * 213972
Commonwealth of Virginia
MI55IQN EXPIRES OCT06ER 31 2024
Nota
My commission expires 14 a,
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