NCC220772_FRO Submitted_20220216

M1
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 orthe e-mail and/orfax information unavailable, place N/A in the blank.)
Part A.
1. Project Name B&B Loop Subdivision
2. Location of land -disturbing activity: County Hoke City or Township McLaughlin
Highway/Street B&B Loop Latitude 34.989997 Longitude 79.140307
3. Approximate date land -disturbing activity will commence: November 15, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 11.1 ac
6. Amount of fee enclosed: $ 780 . 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 Dan Farrell E-mail Address dan(a-)Oandkbuilders.com
Telephone [phone] Cell # 910-684-0648 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rockfish Property. LLP
Name
Telephone
Fax Number
645 Laurinburg Highway
Current Mailing Address Current Street Address
Raeford NC 28376
City State Zip City State Zip
10. Deed Book No. 1279 Page No. 433 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):
Rockfish Property. LLP jamal ,jandkbuilders.com
Name E-mail Address
645 Laurinburg Highwav
Current Mailing Address Current Street Address
Raeford NC 28376
City State Zip City State Zip
Telephone [phone] Fax Number

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
City State Zip
Telephone.
E-mail Address
Current Street Address
City
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
State Zip
E-mail Address
Current Street Address
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.
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Type or print nam Title or Authority
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taw IJpouk a Notary Public of the County of bmix L1 a'd
State of North Carolina, hereby certify that M it h CA v0 I(- 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 h _day of V
Seal
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