NCC242858_FRO Submitted_20240917

He a iooa- 1
Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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 NCG01 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 Ocean Isle Palms
*If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Brunswick City or Township
Highway/Street See Attached Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 11 .36
6. Amount of fee enclosed: $ 1 ,200.00 . 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 ❑ Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Joseph K. Bland, P.E. E-mail [e-mail]
Phone: Office# 910-287-5900 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Toll Southeast LP Company, Inc. 301-399-4925 301-399-4925
Name Phone: Office# Mobile#
1140 Virginia Drive 1140 Virginia Drive
Current Mailing Address Current Street Address
Fort Washington, PA 19034 Fort Washington, PA 19034
City State Zip City State Zip
10. Deed Book No.5182 Page No. 1264 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).
Toll Southeast LP Company, Inc. [e-mail]
Company Name E-mail Address
1140 Virginia Drive 1140 Virginia Drive
Current Mailing Address Current Street Address
Fort Washington, PA 19034 Fort Washington, PA 19034
City State Zip City State Zip
Phone: Office# 301-399-4925 Mobile# [phone]
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:
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)
(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:
United Agent -Group Inc. [e-mail]
Name of Registered Agent E-mail Address
15720 Brixham Hill Avenue #300 15720 Brixham Hill Avenue #300
Current Mailing Address Current Street Address
Charlotte, NC 28277 Charlotte, NC 28277
City State Zip City State Zip
Phone: Office# 561-694-8107 Mobile# [phone]
Mary Boning
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.
Mark MacFarland Vice President - Land Development
Type or print name Title or Authority
July 10, 2024
Signature Date
I, KAL(N LAM P21vET%E , a Notary Public of the County of OM IDSOtJ
State of North Carolina, hereby certify that MiNiat MACFAELMNID 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 (Q day of ...AM , 20 aLt
Nottr Piii=r1RC5fCirth6
Seal
My commission expires 05—a5"a5
KALYN LAPP PRIVETTE
Notary Public, North Carolina
Davidson County
My Commission Expires
May 25,2025

NB Project @24002-1 Ocean Isle Palms
Attachment for 11.36 AC NCDEQ-FRO and BCSW-Fill Grade
Lot# SHALLOTTE,NC 28470 AC Parcel
2 1499 ST.LUCIA DR SW 0.19 243CG002
4 1503 ST.LUCIA DR SW 0.19 243CG004
6 1507 ST.LUCIA DR SW 0.18 243CG006
14 1523 ST.LUCIA DR SW 0.19 243CG014
15 1525 ST.LUCIA DR SW 0.19 243CG015
19 1533ST.LUCIA DR SW 0.19 243CG019
21 1537 ST.LUCIA DR SW 0.19 243CG021
22 1539 ST.LUCIA DR SW 0.19 243CG022
24 1543 ST.LUCIA DR SW 0.19 243CG024
25 1545 ST.LUCIA DR SW 0.19 243CG025
26 1547 ST.LUCIA DR SW 0.24 243CG026
27 1490 ST.LUCIA DR SW 0.25 243CG027
27 1515 ST.VINCENT DR SW CORNER LOT
40 1522 ST.LUCIA DR SW 0.29 243CG040
41 1524ST.LUCIA DR SW 0.19 243CG041
42 1526 ST.LUCIA DR SW 0.19 243CG042
49 1542 ST.LUCIA DR SW 0.19 243CG049
49 6099 MARTINIQUE ST SW CORNER LOT
50 1544 ST.LUCIA DR SW 0.18 243CG050
51 1546 ST.LUCIA DR SW 0.19 243CG051
52 1548 ST.LUCIA DR SW 0.22 243CG052
52 6088 OCEAN ISLE PALMS WAY SW CORNER LOT
55 6080 OCEAN ISLE PALMS WAY SW 0.19 243CG055
56 6078 OCEAN ISLE PALMS WAY SW 0.19 243CG056
61 6093 MARTINIQUE ST SW 0.20 243CG061
62 6095 MARTINIQUE ST SW 0.25 243CG062
76 6072 CALCOS CT SW 0.19 243CG077
87 1561 ST.LUCIA DR SW 0.21 243CH004
89 1565 ST.LUCIA DR SW 0.27 243CH006
90 1569 ST.LUCIA DR SW 0.19 243CH007
90 6098 LUCAYA CIR SW CORNER LOT
91 6096 LUCAYA CIR SW 0.49 243CH008
103 1593 ST.LUCIA DR SW 0.18 243CH020
115 1588 CURACAO DR SW 0.25 243CH032
116 1588 CURACAO DR SW 0.17 243CH033
118 1594 CURACAO DR SW 0.17 243CH035
119 1596 CURACAO DR SW 0.25 243CH036
129 6082 ISLA MONA DR SW 0.24 243CH046
130 6084 ISLA MONA DR SW 0.20 243CH047
131 6086 ISLA MONA DR SW 0.19 243CH048
144 1572 ST.LUCIA DR SW 0.21 243CH061
148 1564 ST.LUCIA DR SW 0.19 243CH065
149 1562 ST.LUCIA DR SW 0.16 243CH066
150 1560 ST.LUCIA DR SW 0.18 243CH067
153 1554 ST.LUCIA DR SW 0.27 243CH070
155 6087 OCEAN ISLE PALMS WAY SW 0.19 243CH072
156 6085 OCEAN ISLE PALMS WAY SW 0.19 243CH073
157 6083 OCEAN ISLE PALMS WAY SW 0.19 243CH074
159 6079 OCEAN ISLE PALMS WAY SW 0.19 243CH076
184 6072 MARTINIQUE ST SW 0.18 243CG105
191 1536 BARBUDA BLVD SW 0.18 243CG112
159 6079 OCEAN ISLE PALMS WAY SW 0.19 243CH076
184 6072 MARTINIQUESTSW 0.18 243CG105
191 1536 BARBUDA BLVD SW 0.18 243CG112
194 1543 BARBUDA BLVD SW 0.24 243CG115
194 6080 MARTINIQUESTSW CORNER LOT
197 1537 BARBUDA BLVD SW 0.19 243CG118
201 1544 ST.VINCENT DR SW 0.22 243CG122
209 1534 ST.VINCENT DR SW 0.15 243CG130
209 1541 ADELAIDE BEACH AVE SW CORNER LOT
478 1578ADELAIDEBEACHAVESW 0.22 243FB009
489 1181 ISLA CABRITOS RD SW 0.25 243FB020