NCC220727_FRO Submitted_20220216

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.
1. Project Name Scot Stor- Pasquotank
2. Location of land -disturbing activity: County Pasquotank City or Township Elizabeth Ci
Highway/Street Beau Parkway Latitude 36.2731 ° N Longitude-76.2841 ° W
3. Approximate date land -disturbing activity will commence: February 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5.
6.
7.
8.
0
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.70
Amount of fee enclosed: $ 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 Kimberly D. Hamby, PE E-mail Address [e-mail]
Telephone [phone] Cell # 252.340.3264 Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Cluny, LLC 252.619.6919
Name Telephone Fax Number
P.O. Box 116 136 Pat's Way
Current Mailing Address
Barco NC
Current Street Address
27917 Barco NC
27917
City State Zip City State Zip
10. Deed Book No. 957 Page No. 599 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.
Clunv, LLC stuartinnes1 @gmail.com
Name E-mail Address
P.O. Box 116 136 Pat's Way
Current Mailing Address
Barco NC
Current Street Address
27917 Barco
NC
27917
City
State
Zip City
State
Zip

Telephone; 252.619.6919
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
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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 of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Stuart Innes
Type or print n e
Signat re
Manager
Title or Authority
/2//" /7- /
Date ' '
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a Notary Public of the County of -Lbe__-_Y �
State of P 2ticgloRa, hereby certify that ��-- 1nncs 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 its day of c(� 2D al
CHELSEY RENE BLOWE
Notary Public
Commonwealth of Virginia Notary
Castration No. 7255188
My E6 s5,cn Expires Sep 30, 2025 I� )OOd'5
My commission expires ;