NCC215224_FRO Submitted_20210916

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 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 McMillan Farm Phase Two - Lots 14-16 33 34 38 & 40
2. Location of land -disturbing activity: Cumberland County City or Township Cedar Creek
Lowgrass Road &
Highway/Street Bastion Place Latitude N35.0550° Longitude W-78.70370
3. 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): 3.48 Acres
6. Amount of fee enclosed: $ 260.00 . 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).
Has an erosion and sediment control plan been filed? Yes No Enclosed x
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brian Walker E-mail Address brianwalker(@hhhomes. corn
Telephone [phone] Cell # Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
WBM AG, LLC
Name
1064 71It School Road
Current Mailing Address
Fayetteville _ _ NC 28314
City State Zip
10. Deed Book No. 10168 Page No. 245
Telephone Fax Number
Same
Current Street Address
Same
City State Zip
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 Fayetteville LLC
Name
2919 Breezewood Ave. Suite 400
Current Mailing Address
Fayetteville NC 28303
City State Zip
Telephone [phone]
E-mail Address
Same
Current Street Address
Same
City State
Fax Number
Zip

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 by any change in the information provided herein.
_ Brian Walker
Type or print name
Signature
Division President
Title or Authority
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State of North Carolina, hereby certify that Y,cls) _C) VOcd\L-a— appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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