NCC241848_FRO Submitted_20240617

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-mall and/
or fax information unavailable, place N/A In the blank.)
Part A. BaileyLake DogPark
1. project Name
Cumberland SeventyFirst
2. Location of land-disturbing activity: County City or Township .
BaileyLake Rd. 35*01'25" N78*59'43"W
Highway/Street Latitude Longitude
3, Approximate date land-disturbing activity will commence:July 5, 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Dog Park
5, Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .44
130.00
6, Amount of fee enclosed: $ , 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameAnthony Ramsey E-mail Address [e-mail]
Telephone [phone] Cell# [phone] Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Fayetteville 919 4331587
Name Telephone Fax Number
121 lamon St
Current Mailing Address Current Street Address
Fayetteville, NC28302
City State Zip City State Zip
10. Deed Book No,0103 Page No.0059 Provide a copy of the most current deed.
Part B,
1. Company(les) or firm(s) who are financially responsible for the land disturbing activity (Provide a
comprehensive list of ail responsible parties on an attached sheet.) If the company or firm Is a sole proprietorship,
the name c•i Me owner or manager may be listed as the financially responsible patty,
Cy of Fay ettevi!!a Parks and
it
Recreation anthonyramassy(Mayettevillenc_gpv
Name E-mail Address
121 Lamon St
Current Mailing Address Current Street Address
Fayetteville NC28302 28302
City State Zip City State Zip
Telephone [phone] Fax Number

1
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:
N/A
Name Email 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 parson engaging In business under an
assumed name, attach a copy of the Certificate of Assumed Narne. 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,
tavie>
yp�or print name Title or Authority
E2o21
Signature Date
0-1/4--AN\--g--
n')cidc“ ., a Notary Public of the County of brabevi c
State of North Carolina, hereby certify that Ptr4hc_nr � appeared
personally before me this day and being duly sworn a knowledged hat the above form was
executed by hint.
Witness my hand and notarial seal, thisjb day of Ju4ne_ , 201
��'�M" JESSICA MAcK•HOWiI,L �i►r� , yn)
Notary Public, North Carolina.
• v j}'�Y= y Cumberland county 0 try
3,� y Co m t o xplres ++
I 1
My commission expires