NCC216788_FRO Submitted_20211208

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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. The Highlands at Bedford, Phase 4 - Lots 171-173, 180-182, 186-189 & 195
1. Project Name and The Midlands at Bedford, Phase 3, Part 2 — Lots 230 & 231
2. Location of land -disturbing activity: County Hoke City or Township McLaughlin Township
Union Street, Bedford Drive
Highway/Street & Springhaven Drive Latitude 35.0378 Longitude-79.1294
3. Approximate date land -disturbing activity will commence: November 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.)- Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.92 Acres
6. Amount of fee enclosed: $300.00-Normal +750.00-Express. The Express Permitting application fee is
a dual charge, The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a
ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres,
after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is
$2,585),
7. Has an erosion and sediment control plan been filed? Yes No Enclosed XXX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brian Walker E-mail Address brianwalker(a)hhhomes -corn
Telephone [phone] Cell #
Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
H&H Constructors of Fayetteville, LLC_
Name
2919 Breezewood Avenue, Suite 400�
Current Mailing Address
910-486-4864 910-485-0463
Telephone Fax Number
Same
Current Street Address
_Fayetteville NC 28303 Same
City State Zip City State .Zip
Highlands Midlands Highlands Midlands
10. Deed Book No. 1376 1376 Page No. 602 596 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 maybe listed as the financially responsible party.
H&H Constructors of Fayetteville, LLC brianwalker()hhhomes.com
Name E-mail Address
2919 Breezewood Avenue, Suite 400
Current Mailing Address
Fayetteville NC 28303
City State Zip
Telephone [phone]
Same
Current Street Address
Same
City State Zip
Fax Number 910-485-0463

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 of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone Fax Num
State zip
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Moorman, Kizer & Reitzel, Inc._
Engineering Firm or other consultant
Dennis A. Gilbert
Individuai contact person (type or print)
d ilbertmkrinc.com
E-mail Address
910-484-5191 910-484-0388
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.
Brian Walker
Type or print name
Signature
A ent
Title or Authority
�3
Dat
a Notary Public of the County of H— 4 e
State of North Carolina, hereby certify that i ,7A r7 iD- GC JcjK e 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 /V ll V-e4nj2C 20-9
ASIA p ,
OTAq �": Notary
Seal �' 1 t
MY _ My commission expires G?
COMMISSION EXPIRES
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