NCC215946_FRO Submitted_20211028

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: Pineview Manor — Lots 1-3 & 17-19
2. Location of land -disturbing activity: County Cumberland City or Township Cross Creek Township
Highway/Street Branson Street & Morgan Street Latitude N 35.0517 Longitude W-78.9003°
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.35 Acre
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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jamie Godwin E-mail Address J@mie(cagresidentiainc.com
Telephone [phone] Cell # 910-850-9881 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
A & G Residential, LLC_ -
Name
916 Arsenal Avenue, Suite B
Current Mailing Address
910-237-7944
Telephone
Same
Current Street Address
Fayetteville NC 28305 Same
10. Deed References' D1311240 PG 796 Copies provided.
Part B.
Fax Number
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):
A & G Residential. LLC
Name
2533 Raeford Road, Suite C
Current Mailing Address T
Fayetteville NC 28305
City State Zip
Telephone [phone]
Jamie(c).agresidentialnc.com
E-mail Address
Same
Current Street Address
Same
City State Zip
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:
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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.
Jamie Godwin
Type or rint name
Sign re
Member -Manager
Title or Authority
Date
Fol-A � e P iii,_'_ w •L' • t a-r-y-PO-1511 i c of • u n t y • _V•�. %Ili
State of North Carolina, hereby certify that JaKi appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this a 3fAay of 20al
(uN E qI/O.,�•.
Seal
NOTARY N
Pit, 2
NotaryEVVI—Id RA "M
My commission expiresI, �.