NCC232681_FRO Submitted_20230927

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 NCGO1 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 Kendall Farms Subdivision
'If this project involves Arnerii.on lN.uscue Plain Act (ARPA) funds. list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI)
2. Location of land-disturbing activity: County Wayne City or Township New Hope
Highway/Street New Hope Rd. (SR1003) Latitude(decimai degrees) g
LOn ItUde(decimal degrees)
3. Approximate date land-disturbing activity will commence: Sept 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 6.52 ac
6. Amount of fee enclosed: $ 1 700 . 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❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name David Perry E-mail Address [e-mail]
Phone: Office* 919-734-4074 x 112 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
ENC New Hope Rd, LLC 740-984-0524
Name Phone: Office# Mobile#
1804 Bloomsbury Rd 1804 Bloomsbury Rd
Current Mailing Address Current Street Address
Greenville, NC 27858 Greenville, NC 27858
City State Zip City State Zip
10. Deed Book No. 3749 Page No. 143 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).
Perry Real Estate Group, LLC [e-mail]
Company Name E-mail Address
PO Box Drawer E 701 Patetown Rd.
Current Mailing Address Current Street Address
Goldsboro, NC 27533 Goldsboro, NC 27530
City State Zip City State Zip
Phone: Office# 919-734-4074 x 112 Mobile# [phone]
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:
N/A
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)
(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)

(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.
4 I 61 11\ W(1
Type o print name Title or Au ority
34.\ 1 I 1 23
Signature Date
I, A-glel iti boy , a Notary Public of the County of )0kYL,S-frikA-
State of North 6rolina, hereby certify that 0 a,,j d Al _ appeared personally
before me this day and being duly sworn acknowledgedy that the above rm was executed by him/her.
Witness my hand and notarial seal, this I o day of -514 ill , 20 23
``,i\1111 n,,,,,,,I''''
'llikfrri
`.fig,, - - �,;, Notary
I— �pTARY ,'. My commission expires 7f 2(l12 7
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' GOLDSBORO BUILDERS SUPPLY FAMILY OF COMPANIES
128590
VendNCDEQ or ID I Name Payment NCDEQ 000000000053532 Number 1Ch��Date I Do12c
ument Number
Invoice Number I Date PO# �— Description Amount Paid I 023f Discount I Net Amount Paid
2307-NEWMAN 7/18/2023 $1,700.00
$0.00 $1,700.00
$1,700.00 $0.00 $1,700.00
(—
ORIGINAL CHECK HAS MULTIPLE SECURITY FEATURES.PRINTED ON CHEMICAL REACTIVE TONER FUSE PAPER-SEE BACK FOR DETAILS
128590
omR eTo- R TRUIST
B_DII.DtS WRIST BUILDERS SUPPLY Pl.�0.
zG ' t'= GOLDSBORO "° TM ,,-Cy. GOLDSBORO,N.C.27530
a BUILDERS SUPPLY M . ,, 66-112
r..''\' " \"le, Ill tl.llllll BUILDERS SUPPLY
FAMILY OF COMPANIES , .'rn.,= -V 531
PO Drawer E•Goldsboro,NC 27533•[phone]
DATE AMOUNT
7/19/2023 $1,700.00
PAY One Thousand Seven Hundred Dollars And 00 Cents
TO THE
ORDER NCDEQ DSBORO BUILDERS SUPPLY MILY OF COMP NIES
OF Attn: 401 Wetlands `0 5ENS,TI` 11
1617 Mail Service Center e �`` 1 tv'_CD-•G _ MP
Raleigh NC 27699-1617