NCC232675_FRO Submitted_20230912

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 N/A in the blank.)
Part A.
1. Project Name Southern Estates
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
Cityor Township Sanford
2. Location of land-disturbing activity: County Lee
Fire Tower Road&Tramway Road 35.441490 -79.186685
Highway/Street _ _ _ Latitude(deoimal degrees) _ Longitude(deamai degrees)
3. Approximate date land-disturbing activity will commence:04-2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):
11 .80
6. Amount of fee enclosed: $ 1,200 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❑ Enclosed ❑x No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name
Nick Tsakanikas E-mail Address [e-mail]
Phone: Office# 919-233-6747 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Adams Homes AEC, LLC 704-558-4527
Name Phone: Office# Mobile#
100 West Garden Street, 2nd Floor
Current Mailing Address Current Street Address
Pensacola, FL 32502
City State Zip City State Zip
10. Deed Book No. 1530 Page No.829 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 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).
Adams Homes AEC, LLC [e-mail]
Company Name E-mail Address
100 West Garden St, 2nd Floor 100 West Garden St, 2nd Floor
Current Mailing Address Current Street Address
Pensacola, FL 32502 Pensacola, FL 32502
City State Zip City State Zip
Phone: Office# 850.934.0470 Mobile#[phone] (Scott)
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:
National Registered Agents, Inc. Privacy Redaction
Name of Registered Agent E-mail Address
160 Mine Lake Ct, Ste 200 160 Mine Lake Ct, Ste 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Phone: Office# Privacy Redaction 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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
Name of Individual to Contact (if Registered Agent is a company)

(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.
William Bryan Adams Manager/Adams Homes AEC, LLC
Type or print name Title or Authority
-C-..,_-2_ -7 . 2 3
Signature Date
I Shelley A. Sepulveda , a Notary Public of the County of ESCambla
State of North Carolina, hereby certify that\te-t 111u C appeared personally
before me this day and being duly sworn acknowledged tha the above form was executed by him/her
Witness my hand and notarial seal, this day of .u•r-4 , 20
44ii—ii4,% SHELLEY A SEPULVEDA '
:° `F=: Notary Public.State of Florida
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