NCC233450_FRO Submitted_20231211

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.
1. Project Name: Kamdon Ranch—EC Plan for Lots 68, 69, and 76 -78
2. Location of land-disturbing activity: County: Johnston City or Township: Hectors Creek
Highway/Street: Retreat Run Latitude: 35.5224 Longitude: -78.4079
3. Approximate date land-disturbing activity will commence: September 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including of site borrow and waste areas): 2.4 acres
6. Amount of fee enclosed: $300.00 The application fee of$100.00 per acre (rounded up to the next
acre) is assessed without a ceiling amount. (Example: an 8.2-acre application fee is$900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed: X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Scott Lee E-mail Address: laura( scottleehomes.com
Telephone: [phone] Cell: [phone] Fax: (919)
9. Landowner(s)of Record (attach accompanied page to list additional owners):
LAST Investments, LLC [phone]
Name Telephone Fax
104 State Avenue, Suite 103 104 State Avenue, Suite 103
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC 27520
City State Zip City State Zip
10. Deed Book No.: 6011 Page No.: 326—328 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.
Scott Lee Homes. Inc. lauraascottleehomes.com
Name E-mail Address
104 State Avenue. Suite 103 104 State Avenue, Suite 103
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC 27520
City State Zip City State Zip
Telephone: [phone] Fax (919)

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:
Name E-mail Address
Current Mailing Address Current Street Address
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:
Laura S. Lee laurascottleehomes.com
Name of Registered Agent E-mail Address
104 State Avenue. Suite 103 104 State Avenue, Suite 103
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC 27520
City State Zip City State Zip
Telephone [phone] Fax Number (919)
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.
P. Scott Lee President, Scott Lee Homes, Inc.
Type or print name Title or Authority
?Y)- to-
Signat re Dat
I, c eA1 LW+ci 0 113 )u- t , a Notary Public of the County of J vw ,\61,
State of North Carolina, hereby certify that _ SCC 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 i L_. day of ( .•tt,,nt„ , 2023
ti oonninprtPry°
, t / A4 A to ,2
� t
��c°; " V Notary
S� Seal
°¢,L.O%
My commission expires -
!,r#h#tlnn}ni4*",