NCC220726_FRO Submitted_20220215

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: The Meadows at Roslin Farms West Section 2 - Lots 229 233 & 234
2. Location of land -disturbing activity- County Cumberland City or Township Rockfish Township
Highway/Street Running Fox Road Latitude N 34.9091 ° Longitude W-78.9486°
3. Approximate date land -disturbing activity will commence: January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.69 Acres
6. Amount of fee enclosed: $ 200.00 . The application fee of $100.00 per acre (rounded up
to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
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 Pamela Geddie E-mail Address Pam cavinessandcates.com
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Roslin Farms, LLC 910-481-0503 910-481-0585
Name Telephone Fax Number
2919 Breezewood Avenue, Suite 400 Same
Current Mailing Address Current Street Address
Fayetteville NC 28303 Same
City State Zip City State Zip
10. Deed Book No. 9829 Page No 575 __ Provide 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):
Caviness & Cates Building and Develooment Co
Name
639 Executive Place, Suite 400
Current Mailing Address
Fayetteville NC 28305
City State Zip
Telephone [phone]
E-mail Address
Same
Current Street Address
Same
City State Zip
Fax Number 910-481-0585

(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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
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.
Patrick Rgynor
Type or print game
Sign ure
Chief Financial Officer/Treasurer
Title or Authority
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-. a Notary Public of the County of ur U-C� d
State of North Carolina. hereby certify that appeared
personally before me this day and being du& sworn acknowlecTged t at the above form was
executed by him.
Witness my hand and notarial seal, this
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