NCC204625_MODIFICATION Supporting Documents_20230324 (2)

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. Calabash Palms
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Shallotte
Highway/Street Calabash Rd NW (SR-1300) Latitude 33055'6.85" Longitude 78036"0.20"
3. Approximate date land -disturbing activity will commence: Underway (existing permit)
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.56 acres
6. Amount of fee enclosed: $ 0 (NO CHANGE IN DESIGN). 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bryant Spencer E-mail Address [e-mail]
Telephone [phone] Cell # 910-308-0804 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CALABASH TOWNHOMES LLC 910-486-4864 910-485-0463
Name Telephone Fax Number
2919 BREEZEWOOD AVE 2919 BREEZEWOOD AVE
Current Mailing Address Current Street Address
FAYETTEVILLE, NC 28303-5501 FAYETTEVILLE, NC 28303-5501
City State Zip City State Zip
10. Deed Book No. 4453 Page No. 548 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Calabash Townhomes, LLC DAVIDVANNOYQa HUFFFAMILYOFFICE.COM
Name
E-mail Address
2919 Breezewood Ave, Suite 400 2919 Breezewood Ave, Suite 400
Current Mailing Address Current Street Address
Fayetteville, NC 28303-5238 Fayetteville, NC 28303-5238
City
State Zip City
State
Telephone [phone] Fax Number [phone]
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:
N/A
Name E-mail Address
Current Mailing Address
City
Telephone.
Current Street Address
State 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:
N/A
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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.
David Vannoy Manager
Type or print name
Signature
Title or Authority
Date
, a Notary Public of the County of
State of North Carolina, hereby certify that 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 day of
Seal
Notary
My commission expires
W