NCC220620_FRO Submitted_20220209

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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. Sp encer s Woods S/D ESC Plan
1. Project Name
2. Location of land -disturbing activity: County_Edgecombe City or Township Tarboro
Highwayistreet Spencer Drive _Latitude 35.876506 Longitude -77.581679
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): 32.9 Acres
6. Amount of fee enclosed. S$2,000+2,145 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per 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). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Barton Horne E-mail Address barton [e-mail]
Telephone [phone] _ cell # 252-746-7628 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners): *See Attached
Big Time Grand, LLC . 252-903-9889 '
Name Telephone Fax Number
4460 Meadowbrook Rd. 4460 Meadowbrook Rd.
Current Mailing Address Current Street Address
High Point NC 27265 Rocky Mount NC 27801
City State Zip City State Zip
*See Attached
10. Deed Book No. 1738 -Page No. 1013 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.
Big Time Grand, LLC [e-mail]
Name E-mail Address
4460 Meadowbrook Rd. 4460 Meadowbrook Rd.
Current Mailing Address Current Street Address
Rocky Mount NC 27801 Rocky Mount NC 27801
City State
Telephone [phone]
Zip City
Fax Number
State
Zip

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
E-mail Address
Current Street Address
City State Zip City
Telephone 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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(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:
Appian Consulting Engineers, P.A. [e-mail]
Engineering Firm or other consultant E-mail Address
David Revoir 252-972-7703
Individual contact person (type or print) 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.
C.B. Daughtridge Managing Member
Ty e or pr na a Title or Authority
t A I
Signature Da e
------------------- ------- -----------------._._----------------------------------------------------------
a Notary Public of the County of
V r` r
State of North Carolina, hereby certify that I w>ti%r�� appeared personally
before me this day and being duly sworn acknowledged that the a0ve form Qs executed by him.
Witness my hand and notarial seal, this day of
�FA EDWARDS NELMS
j NOTARY PUBLIC
NASH COUNTY, NC
My Commission Expires 11-30-2025
, 20a\
My commission expires 1\ - - aoa 5