NCC220830_FRO Submitted_20220303

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 The Villas at Shingletree
2. Location of land -disturbing activity: County Brunswick City or Township Carolina Shores
Highway/street Shingletree Rd Latitude 33.92234 N Longitude 78.58145 W
3. Approximate date land -disturbing activity will commence:
4
1 /1 /2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 21.14
6. Amount of fee enclosed: $ 100 . 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 Sammy Gay E-mail [e-mail]
Telephone [phone] cell # 843-457-4051 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
RRCAP FA Shingletree, LLC 980-223-6026 843-347-2792
Name Telephone Fax Number
517 Alcove Rd Ste 301 517 Alcove Rd Ste 301
Current Mailing Address Current Street Address
Mooresville, NC 28117 Mooresville, NC 28117
City State Zip City State Zip
10. Deed Book No. 04614 Page No. 0918 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.
RRCAP FA Shingletree, LLC [e-mail]
Name E-mail Address
517 Alcove Rd Ste 301 517 Alcove Rd Ste 301
Current Mailing Address Current Street Address
Mooresville, NC 28117 Mooresville, NC 28117
City
State
Telephone [phone]
Zip City State Zip
Fax Number 843-347-2792

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
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:
Jerry Mosley
[e-mail]
Name of Registered Agent E-mail Address
517 Alcove Rd Ste 301 517 Alcove Rd Ste 301
Current Mailing Address
Mooresville, NC 28117
City
State Zip
Telephone [phone]
Current Street Address
Mooresville, NC 28117
City State Zip
Fax Number 843-347-2792
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.
Jerry Mosley Owner
Type of -I t na '
11,
Ggn . re
----=-------- -------
State of North Ca
personally before
executed by him.
Title or Authority
JO Ve w 6,/Y J0►Z02-I
Date
a Notary Public of the County of
rolina, hereby certify that W-C4 moS f e appeared
me this day and being duly s rn acknowle ed that the above form was
Witness my hand and notarial seal, this ay of dMW►1t/V 20
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