NCC215193_FRO Submitted_20210915

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
Project Name Maxwell Ridge, Phase 1 - Lots 1-4 & 13-16
Location of land -disturbing activity: County Hoke City or Township _Quewhiftle Township
Highway/Street�Mildred Way Latitude N35.09140 Longitude W-79.39630
Approximate date land -disturbing activity will commence:August 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.71 Acres
6. Amount of fee enclosed: $ 390.00 . 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:
Name Brian Walker E-mail Address BrianWalker(@hhhomes.com
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Huff Rokoski Development, LLC 910-486-4864 910-485-0463
Name Telephone Fax Number
2921 Breezewood Ave. Same
Current Mailing Address Current Street Address
Fayetteville
NC
28303
Same
City
State
Zip
City State Zip
10. Deed Book No.
1334 Page No.
167
Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
H&H Constructors of Favetteville, LLC
Name
2919 Breezewood Ave., Suite 400
Current Mailing Address
Fayetteville NC 28303
City State Zip
Telephone [phone]
E-mail Address
Current Street Address
Same
City State Zip
FaxNumber 910-485-0463

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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 by any change in the information provided herein.
Brian Walker Division Manager & Agent
nt _
Type or print name Title or Authority
-i� . �d �Z3 2 d
Signature Date
I, /°tT"iw VcLk C'L L>oL; t a Notary Public of the County of t_tte
State of North Carolina, hereby certify that &7CUf tti4j" appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by hire.
Witness my hand and notarial seal, this Z—' day of 01X " , 20
ASIA O
Q' t10TApr �� Notary
Seal coM MY
ExPIRes My commission expires
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