NCC220635_FRO Submitted_20220204

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.
1. Project Name GOLF COURSE ROAD RESIDENTIAL DEVELOPMENT
2. Location of land -disturbing activity: County LEE City or Township WEST SANFORD TOWNSHIP
Highway/Street GOLF COURSE ROAD Latitude 35 DEG 30' 48" Longitude 79 DEG 10' 37"
3. Approximate date land -disturbing activity will commence: JUNE 2021
4_ Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):3.0 AC
6. Amount of fee enclosed: $195. 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 Mr. Brandon Harrington E-mail Address brand on(Wharrinptonprope rtiesofnc.com
Telephone NIA Cell # 919-770-6969 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
HARRINGTON PROPERTIES OF NC LLC 919-770-6969 N/A
Name Telephone Fax Number
2659 SAN LEE DRIVE SAME
Current Mailing Address Current Street Address
SANFORD NC 27330 _
City State Zip City
State
10. Deed Book No. 01493 Page No. 0368 Provide a copy of the most current deed.
Part B.
Zip
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties an an attached sheet):
HARRINGTON,PROPERTIES OF NC, LLC
Name
2659 SAN LEE DRIVE
Current Mailing Address
brandga@harringLtonpror)ertiesofnc.com
E-mail Address
SAME
Current Street Address
SANFORD NC 27330
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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
Telephone Fax Number
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.
BRANDON HARRINGTON MANAGING MEMBER
Type or tint name Title or Authority
3-
Signature Date
JCVIMP� _ �,C�Uo , a Notary Public of the County of L ��
State of North Carolina, hereby certify that[3 [O Y1 C)1/1 10 r rt f t 4 appeared
personally before me this day and being duly sworn acknowledged that thA above form was
executed by him..
Witness mypg(W,gnd notarial seal, this
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