NCC233598_FRO Submitted_20231228

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 Graceland, Phase I IA— Lots 1-3, 34-37 &40-45
*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).
2. Location of land-disturbing activity: County Hoke City or Township McLauchlin Township
Presley Street &
Highway/Street Calhoun Street Latitude(deama]degrees)N 34.9621° Longitude(deama,degrees)W-79.0823°
3. Approximate date land-disturbing activity will commence: November 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5.34 Acres
6. Amount of fee enclosed: $ 600.00 . 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 E Enclosed ® No
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Daniel Furr E-mail Address danielfurrAfurrconstruction.com
Phone: Office# 910-391-3670 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Furr Construction and Development, Inc. 910-391-3670
Name Phone: Office# Mobile #
P.O Box 2824 327 Dick Street, Ste 102
Current Mailing Address Current Street Address
Fayetteville NC 28302 Fayetteville NC 28301
City State Zip City State Zip
Lots 1, 2, 34 & 3-" 2, 34 & 3
10. Deed Book No. 1507 Page No. 755 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).
Furr Construction and Development, Inc. [e-mail]
Company Name E-mail Address
P.O Box 2824 327 Dick Street, Ste 102
Current Mailing Address Current Street Address
Fayetteville NC 28302 Fayetteville NC 28301
City State Zip City State Zip
Phone: Office# 910-391-3670 Mobile#
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:
[e-mail]
Name of Registered Agent E-mail Address
P.O Box 2824 327 Dick Street, Ste 102
Current Mailing Address Current Street Address
Fayetteville NC 28302 Fayetteville NC 28301
City State Zip City State Zip
Phone: Office # 910-391-3670 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.
L n V r( _ Reg. Agent
Type or print name Title or Authority
Signature Date
I, TMlor J SKI( , a Notary Public of the County of C.vm otV\ 11d
State of North Carolina, hereby certify that D041\el 'Urr appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him/her.
Witness my hand and notarial seal, this 30 day of dC}ObeC , 20 23
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Notary
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Furr Construction and Development, Inc. 910-391-3670
Name Phone: Office # Mobile#
P.O Box 2824 327 Dick Street, Ste 102
Current Mailing Address Current Street Address
Fayetteville NC 28302 Fayetteville NC 28301
City State Zip City State Zip
Lots 3, 36, 44 &45 Lots 3, 36, 44 &45
Deed Book No. 1507 Page No. 851 Provide a copy of the most current deed.
Landowner 3 of Record:
Furr Construction and Development, Inc. 910-391-3670
Name Phone: Office# Mobile#
P.O Box 2824 327 Dick Street, Ste 102
Current Mailing Address Current Street Address
Fayetteville NC 28302 Fayetteville NC 28301
City State Zip City State Zip
Lot 43
Deed Book No. 1508 Page No. 240 Provide a copy of the most current deed.
Landowner 4 of Record:
Furr Construction and Development, Inc. 910-391-3670
Name Phone: Office# Mobile#
P.O Box 2824 327 Dick Street, Ste 102
Current Mailing Address Current Street Address
Fayetteville NC 28302 Fayetteville NC 28301
City State Zip City State Zip
Lots 37, 40, 41 &42 Lots 37, 40, 41 &42
Deed Book No. 1508 Page No. 289 Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.