NCC240016_FRO Submitted_20240110

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. Cox Tract
1. Project Name
2. Location of land-disturbing activity: County Columbus City or Township Tabor
Highway/Street Swamp Fox Hwy Latitude 34-08-03 Longitude 78-51-39
3. Approximate date land-disturbing activity will commence:02/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):30.0
6. Amount of fee enclosed: $ 3,000.00 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
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 Steve Shuttleworth E-mail Address [e-mail]
Telephone [phone] Cell# 719-499-1373 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jonathon Cox
Name Telephone Fax Number
110 Lakeside Drive
Current Mailing Address Current Street Address
Tabor City NC 28463
City State Zip City State Zip
10. Deed Book No. 1088 Page No.777 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 maybe listed as the financially responsible party.
Shuttleworth Inc. [e-mail]
Name E-mail Address
711 Carolina Beach Ave. North
Current Mailing Address Current Street Address
Carolina Beach NC 28428
City State Zip City State Zip
Telephone [phone] Fax Number 719-623-0473

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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
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.
Steve Shuttleworth President
Type or print name Title or Authority
Steve Shuttleworth Digitally signed by SteveShuttleworth 9-13023
Date:2023.09.13 15:10:27-04'00'
Signature Date
I, ('JI I i tJ M 1/it t I , a Notary Public of the County of
State of North Carolina, hereby certify that 5 ti 040,00 1obi 4-- 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 `{r day of , 20
Notary
Seal Dn f O2 /A0 /„
My commission expires L L J/�Cy
Callie M Hall
Notary Public
New Hanover County, NC
My Commission Expires 2/2/2026