NCC215866_FRO Submitted_20211021

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 Environmental Quality. Submit the completed form to the appropriate
Regional Office. (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 Courtyards by Carrell
2. Location of land -disturbing activity: County Brunswick City or Township
Highway/Street Ocean Hwy W. Latitude 33.948893 Longitude-78.499001
3. Approximate date land -disturbing activity will commence: 111122
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
0.73
6. Amount of fee enclosed: $ 65.00 . 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bruce Carrell E-mail Address [e-mail]
Telephone [phone] Cell # 843-685-1081 Fax #
M
Landowner(s) of Record (attach accompanied page to list additional owners):
Carrell Homes LLC
Name Telephone
4422 Little River Inn Lane same as mailing address
Current Mailing Address Current Street Address
Little River SC 29566
Fax Number
City State Zip City State Zip
10. Deed Book No. 04649 Page No. 1089 Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Carrell Homes LLC [e-mail]
Name E-mail Address
4422 Little River Inn Lane same as mailing address
Current Mailing Address Current Street Address
Little River Sc 29566
City State Zip
City State Zip

Telephone [phone] Fax Number
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:
Bruce Carrell [e-mail]
Name
120 South 3 Street
Current Mailing Address
Wilmington NC 28401
City State Zip
Telephone [phone]
E-mail Address
same as mailing address
Current Street Address
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:
Bruce Carrell
Name of Registered Agent
120 South 3 Street
Current Mailing Address
Wilmington NC 28401
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
same as mailing 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 shouldAere be any change in the information provided herein.
Bruce Carrell I \ President, Carrell Homes LLC.
Typf-urint nakXe i\ I Title or Authority
Signature I— \ Date
I,4LIs', c•L ,C� //e-i ✓t Z a Notary Public of the County of _�40 'O-V
�pu. t1-�r
State of NeR Carolina, hereby certify that Arl"_ e- 6111-e-/1 appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hang, no notarial seal, this o? day of _Se_e+c_m yc.r 20 vx/
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