NCC220677_FRO Submitted_20220214

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 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. Pine Reserve Apartments
1. Project Name
2.
3.
4.
5.
6.
7.
8.
0'
Location of land -disturbing activity: County Lee City or Township Sanford
Highway/Street Center Church Rd Latitude 3502613.8"N Longitude 7901317.1 "W
Approximate date land -disturbing activity will commence- Winter 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 110 + 2.0 acres
Amount of fee enclosed: $ $845.00 + $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).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Braden Riley E-mail Address [e-mail]
Telephone [phone] Cell # N/A Fax # N/A
Landowner(s) of Record (attach accompanied page to list additional owners):
Pine Reserve LLC 919-601-1217
N/A
Name
Telephone Fax Number
20 Birkdale Dr
20 Birkdale Dr
Current Mailing Address
Current Street Address
Pinehurst NC
28374 Pinehurst NC 28374
City State
Zip City State Zip
10. Deed Book No. 1563
Page No. 936 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.
Pine Reserve LLC - Braden Riley [e-mail]
Name
E-mail Address
20 Birkdale Dr
20 Birkdale Dr
Current Mailing Address
Current Street Address
Pinehurst NC
28374 Pinehurst NC 28374
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:
N/A
N/A
Name
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State Zip
City State Zip
Telephone N/A
Fax Number 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:
Braden Riley
[e-mail]
Name of Registered Agent
E-mail Address
20 Birkdale Dr
20 Birkdale Dr
Current Mailing Address
Current Street Address
Pinehurst NC 28374
Pinehurst NC 28374
City State Zip
City State Zip
Telephone [phone]
Fax Number N/A
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.
Braden Riley
Type of print name
a -
Signature
Title or A tho Ity
I 01
Date
a Notary Public of the County of -e
State of North Carolina, hereby certify that r fi , �! 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 .1 s , 20�
Notary Y • l..;ri button
NOT,IF�Y PUBLIC
Seal Moore County
My commission expires
MY Commission Expires March 14, 2023