NCC233521_FRO Submitted_20231129

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.
1. Project Name Songbird Landing Phase 1, Section 1 (PENDE-2020-001)
2. Location of land-disturbing activity: County Pender City or Township Topsail Township
Highway/Street SR 1566 Latitude 34.4017 Longitude -77, 6450
3. Approximate date land-disturbing activity will commence: Permit issued 8/2/2019
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
permittee name change--
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): no additional disturbance
6. Amount of fee enclosed: $ NA . 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 Andy Mills E-mail Address [e-mail]
Telephone Cell# 910-530-4300 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Signature Songbird NC, Ltd., LP 713-822-3891
Name Telephone Fax Number
4307 Peeble Drive 4307 Peeble Drive
Current Mailing Address Current Street Address
Wilmington NC 28412 Wilmington NC 28412
City State Zip City State Zip
10. Deed Book No. 4684 Page No. 293 Provide a copy of the most current deed.
Part B.
1. 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):
Clayton Properties Group, Inc. [e-mail]
Name E-mail Address
PO Box 4098 5000 Cla ton Road
Current Mailing Address Current Street Address
Maryville TN 37802 Maryville TN 37804
City State Zip City State Zip
Telephone [phone] Fax Number

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:
CT Corporation System
Name E-mail Address
160 Mine Lake Court, Suite 200 160 Mine Lake Court, Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone 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:
CT Corporation System
Name of Registered Agent E-mail Address
160 Mine Lake Court, Suite 200 160 Mine Lake Court, Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone 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.
Scott Bowser, Assistant Secretary, Clayton Properties Group, Inc.
Type or print name Title or Authority
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sig ature c Date
I, h , a Notary Public of the County of -kit 2. , _
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State of NeFt+r-GaFetina,hereby certify that $cr* 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 0 day of 'jib , 20 AO
Not
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My commission expires CWR, � �