NCC215785_FRO Submitted_20211019

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.
L Project Name Shelton Beard Road Lots 1 2 5 6 7 8 7C1 7C2 and 7C3
2. Location of land -disturbing activity: County Cumberland City or Township Cedar Creek Township
Highway/Street Shelton Beard Road Latitude 35.0382730 Longitude-78.744929°
3. Approximate date land -disturbing activity will continence: September 08 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.98 acres
6. Amount of fee enclosed: $ 325.00 . 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 Benjamin Stout
Telephone [phone];9
E-mail Address ben(a-)benstoutconstruction.com
Cell # 910-476-4502 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Benjamin Stout Real Estate Services Inc. _
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. 11199 Page No. 570 Provide a copy of the most current deed
Deed Book 11193 Page 537 , Deed Book 11147 Page 51 , Deed Book 11178 Page 786,
Deed Book 11118 Page 734, Deed Book 11104 Page 341, Deed Book 11104 Page 349
Part B.
1. Benjamin Stout Real Estate Services Inc.
Name
PO Box 53798
Current Mailing Address
Fayetteville NC 28305
City State Zip
Telephone [phone]
ben(c benstoutconstruction com
E-mail Address
1786 Metromedical Drive
Current Street Address
Fayetteville NC 28305
City State Zip
Fax Number N/A

2. 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
Telephone
State Zip
E-mail Address
Current Street Address
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 be any change in the information provided herein.
Benjamin Stout President
TygTjt nat c Title or A<<tliority
Signature Date
I, a Notary Public of the County of Q tk
State of North Carolina, hereby certify that Benjamin Stout appeared personally before me this
day and being, P'W eq ,Acknowledged that the above form was executed by him.
Witnes�rrc�tmalribtafeal, this day of .2021
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NOTgRY N , U,
Notary
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My commission expires
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