NCC215796_FRO Submitted_20211018

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 N/A in the blank.)
Part A.
1. Project Name Ethan's Place Lots 1, 4, 5, 6 and 7
2. Location of land disturbing activity: County Cumberland City or Township Rockfish
Highway/Street Duncan St Latitude 34.9800641 Longitude-78.9515860
3. Approximate date land -disturbing activity will commence October 07, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (includ-rig off -site borrow and waste areas): 1.03 acres
6. Amount of fee enclosed: $ 130.00. 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Manno Guerrier _ E-mail Address manno 2g 000P_yahoo.com
Telephone_ 910-261-3965 Cell # 910-261-3965 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Manno Guerrier
Name
3909 Oblu Court
Current Mailing Address
Fayetteville NC 28306
City State Zip
910-261-3965 N/A
Telephone Fax Number
3909 Oblu Court
Current Street Address
Fayetteville NC 28306
City State Zip
10, Deed Book No. 11217 Page No. 328 Provide a copy of the most current deed.
Part 13.
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).
Manno Guerrier
Name
3909 Oblu Court
Current Mailing Address
manno 2g 000 yaboo.com _
E-mail Address
3909 Oblu Court
Current Street Address
Fayetteville, NC 28306 Fayetteville, NC 28306
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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
Fax Number
Zip
(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 be any change in the information provided herein.
Manno Guerrier Owner
Type or pr' a_nwTitle or Authority
09/22/2021
Signature Date
I, Lori Simpson Epler , a Notary Public of the County of Cumberland
State of North Carolina, hereby certify that Manno Guerrier appeared personally before me this
k-lay and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 22th day of September , 20 21
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