NCC215217_FRO Submitted_20210927

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.
1. Project Name Tyson's Corner Lots 1A, 1, and 2
2. Location of land -disturbing activity: County Cumberland City or Township Grays Creek
Highway/Street NC Hwy 871 Grays Creek Church Rd Latitude 34.9026490 Longitude-78.8534111
3. Approximate date land -disturbing activity will commence: August 18, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.41 acres
6. Amount of fee enclosed: $ 195.00. 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Benjamin Stout E-mail Address ben ,benstoutconstruction.com
Telephone [phone] Cell # 910-476-4502 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Benjamin Stout Real Estate Services, I_nc.
Name
PO Box 53798
Current Mailing Address
Fayetteville NC 28305
City State Zip
910-779-0019 910-779-0029
Telephone Fax
1786 Metromedical Drive
Current Street Address
Fayetteville NC 28305
City State Zip
10. Deed Book No. 11046 Page No. 112 Provide a copy of the most current deed
Deed Book No. 11171 Page No. 668
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):
Benjamin Stout Real Estate Services Inc.
Name
PO Box 53798
Current Mailing Address
Fayetteville NC 28305
City State Zip
ben §benstoutconstruction.com
E-mail Address
1786 Metromedical Drive
Current Street Address
Fayetteville NC 28305
City State Zip
Telephone [phone] Fax Number NIA

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
E-mail 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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone Fax
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.
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Typ rint name
Signa e
President
Title or Authority
L 2-1
Date
I, , a Notary Public of the County of G�m%PY�QIf7�
State of North Carolina, hereby certify that n % appeared personally before me this
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day a�jd%Bg1nP(juj�yyO&Worn acknowledged that the above form was executed by him.
i S!SAW h6an nofa�lal seal, this. day of 2021
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