NCC216178_FRO Submitted_20211109

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 N/A in the blank.)
Part A. MOORLAND COVE
1. Project Name
2. Location of land -disturbing activity: County CARTERET City or Township MOREHEAD CITY
Highway/Street COUNTRY CLUB RD Latitude N34D44'1 Oil Longitude W76D46'47"
3. Approximate date land -disturbing activity will commence: APRI L 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): APARTMENTS
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.50
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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name FRANKIE W PENDERGRAPH E-mail Address [e-mail]
Telephone [phone] cell # 9197550558 Fax # NONE
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MOORLAND COVE, LP 9197550558 NONE
Name Telephone Fax Number
3924 BROWNING PLACE, SUITE 1 SAME
Current Mailing Address Current Street Address
RALEIGH, NC 27609 SAME
City State Zip City State Zip
10. Deed Book No. 1 710 Page No. 380 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.
M'260-%A ih coVE . a F?l6WOERGLA PN Q IrAt 'POW 5, . c*a%
Name E-mail Address
3°IZ'�- QRowN�N� PLac. STJ 1 'VAS
Current Mailing Address Current Street Address
RALL ► 4 w N C. 'Lot (. o ot 5h �,4
City State Zip City State Zip
Telephone glamssoss $ Fax Number NONE

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
E-mail Address
Current Mailing 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
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.
FRANKIE W. PENDERGRAPH OWNER
Type t na e Title or Authority
Signature Date
I, Y Or <<f i1G 1 a Notary Public of the oun y of
State, of North Carolina, hereby certify that appeared
personally before me this day and being dmy sworn acknowledged th t�t a Fove form was
executed by him.
Witness my hand and notarial seal, this day of , 20��
i MARILYN HERNANDEZ
Notary Public, North Carolina
k Wake County
SeRICommission Expires
July 07, 2022 My
ission expires