NCC233466_FRO Submitted_20231122

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. Habitat for Humanity Restore
1. Project Name
2. Location of land-disturbing activity: County Brunswick City or Township Leland
Highway/Street 92 Dresser LN Latitude 34.239 Longitude-78.007
3. Approximate date land-disturbing activity will commence:November 23, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.47
6. Amount of fee enclosed: $ NA . 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 Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mike White E-mail Address [e-mail]
Telephone [phone] Cell# 910-622-6858 Fax# NA
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Brunswick County Habitat for Humanity 910-454-0007 NA
Name Telephone Fax Number
Carlo Montagano 1323 Stone Chimney Road SW
Current Mailing Address Current Street Address
Supply NC 28462 Same as Above
City State Zip City State Zip
10_ Deed Book No.4246 Page No.554 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.
Brunswick County Habitat for Humanity Inc. [e-mail]
Name E-mail Address
1323 Stone Chimney Road Same as Mailing Adress
Current Mailing Address Current Street Address
Supply NC 28462 Same
City State Zip City State Zip
Telephone [phone] Fax Number NA

., .,,. ... ,.,..,.. ,...,.,IN.0,11MI",.,,.y..,IL.
NA NA
Name E-mail Address
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Telephone NA Fax Number NA
(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:
NA NA
Name of Registered Agent E-mail Address
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Telephone NA Fax Number NA
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.
Carlo Montagano Executive Director
Type or print name Title or Authority
Carlo Montagano 11-16-23
Signature do.z/ 72� Date
I, KO(C. 'LtI L. Woo- e v\ , a Notary Public of the County of 'fit, ) kuivfx
State of North Carolina, hereby certify that Cc Y1 C) r V\ 0 Y CUI v appeared
personally before me this day and being duly sworn acknowledged that Oe above form was
executed by him.
1 � I
Witness my hand and notarial seal, this a o day of IV Q\);ivy1 , 20 a5
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