NCC216645_FRO Submitted_20211130

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 Edgewater on Lake Tillery — Phase 2
2. Location of land -disturbing activity: County: Stanly City or Township Norwood
Highway/Street Edgewater Drive Latitude N 35' 16' 40" Longitude W 800 6' 1"
3. Approximate date land -disturbing activity will commence .tune 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.6
6. Amount of fee enclosed: $ 910_. 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 Robbie Cohen E-mail Address robbie(deohenconstructionco.com
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Edgewater Developers, Inc.
Name
5022 Wrightsville Avenue _
Current Mailing Address
Wilmington NC 28403
City State Zip
10. Deed Book No. DB 1225: PG 102
Part B.
910-393-7202 910-791 -3249
Telephone Fax Number
PO BOX 4127
Current Street Address
Wilmington NC 28406
City State zip
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):
Edaewater Developers, Inc.
Name
5022 Wrightsville Ave
Current Mailing Address
Wilmington NC 28403
City State Zip
Telephone [phone]
E-mail Address
PO BOX 4127
Current Street Address
Wilmington NC _ 28406
City State Zip
Fax Number 910-791-3249

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 State
Telephone
E-mail Address
Current Street Address
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
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 by any change in the information provided herein.
Vice President
Title or Authority
31,8�2a21
Date
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I, Carth-C e�± a Notary Public of the County of
State of North Carolina, hereby certify that _6wri, ffle'414-'kcohco 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 day of 1'1 oLrC41 , 20 Z l
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