NCC220741_FRO Submitted_20220214

(ATTACHMENTA)
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: MP Jacksonville, LLC
2. Location of land -disturbing activity: Onslow County City or Township: City of Jacksonville
Highway/Street: Northwest Drive Latitude: 34047'54.67" Longitude: 77o 25'4.51"
3. Approximate date land -disturbing activity will commence: January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial (Hotel)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.10
6. Amount of fee enclosed: 1, 475.00
The application fee of $225.00 for the first acre plus $125 for every additional acre (rounded up to the
next acre) is assessed without a ceiling amount. (Example: 6.4-acre application fee is $975).
7. Has an erosion and sediment control plan been filed? Yes ❑ No ❑ Enclosed 0
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name: Edward A. Murphy E-mail Address: [e-mail]
Telephone #: [phone] Cell #: N/A Fax #: N/A
9. 8009 Wolftrap Road 8009 Wolftrap Road
Current Mailing Address Current Street Address
Vienna VA 22027 Vienna VA 22027
City State Zip City State Zip
10. Deed Book: 5086 Page Number: 308 (Prowde a copy of the most current deed)
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):
MP Jacksonville, LLC [e-mail]
Name
8009 Wolftrap Road
Current Mailing Address
E-mail Address
8009 Wolftrap Road
Current Street Address
Vienna VA 22027 Vienna
City State Zip
Telephone #: [phone] Cell #:
City
N/A
VA 22027
State Zip
Fax #- N/A

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
the designated North Carolina Agent:
Justin J. Cosgrove / Tidewater Associates, Inc. [e-mail]
Name E-mail Address
306 New Bridge Street 306 New Bridge Street
Current Mailing Address Current Street Address
Jacksonville NC 28540 Jacksonville NC 28540
City State Zip City State Zip
Telephone #: [phone] Cell #: N/A Fax #: N/A
(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:
N/A N/A
Name E-mail Address
N/A
Current Mailing Address
N/A
City
Telephone #: N/A
N/A
Current Street Address
N/A
State Zip City
Cell #: N/A
state
Fax #: N/A
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.
Edward A. Mu phy Registered Agent
Type or pdntFjgffie Title or Authority
Signature Date
I, a Notary Public of the Co y of C'\t' Ay-c1 ar �c,.
State of v a&a, hereby certify that �Uwojr A . , M \3f �nV 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
Seal;
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