NCC216632_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 N/A in the blank.)
Part A.
1. Project Name: Kamdon Ranch — EC Plan for Lots 8 and 54 - 56
2. Location of land -disturbing activity: County: Johnston City or Township: Hectors Creek
Highway/Street: Pioneer St Latitude: 35.5241 Longitude: - 78.4075
3. Approximate date land -disturbing activity will commence: August 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.9 acres
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: Scott Lee E-mail Address: laura(),scottleehomes.com
Telephone: [phone] Cell: [phone] Fax: (919)
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Scott Lee Homes, Inc. [phone]
Name Telephone Fax
104 State Avenue, Suite 103 104 State Avenue, Suite 103
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC 27520
City State Zip City State Zip
10. Deed Book No.: 5909 Page No.: 1 — 3 Provide a copy of the most current deed.
5886 388 - 390
5971 732 - 733
Part B.
1. 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):
Scott Lee Homes, Inc.
Name
104 State Avenue. Suite 103
Current Mailing Address
Clayton NC 27520
City State Zip
Telephone: [phone]
scott(a-)scottleehomes.com
E-mail Address
104 State Avenue, Suite 103
Current Street Address
Clayton NC 27520
City State Zip
Fax (919

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
Fax Number
State Zip
(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. -
Laura S. Lee
Name of Registered Agent
104 State Avenue, Suite 103
Current Mailing Address
laura .scottleehomes.com
E-mail Address
104 State Avenue, Suite 103
Current Street Address
Clayton NC 27520 Cla
City State Zip City
Telephone [phone] Fax Number (919)
NC 27520
State Zip
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.
P. Scott Lee
L e or r nt-name
L:::�=
S'gnatur
President, Scott Lee Homes, Inc.
Title or Authority
Date
I, I ti �Gri _ a Notary Public of the County of
State of North Carolina, hereby certify that R 'r�cj H- 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 2021
AT K11Vq
Notary
Seal v'
a =
My commission expires