NCC220986_FRO Submitted_20220310

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A. Sunset Beach Senior Apartments
1. Project Name
E
3.
4.
5.
6.
Location of land -disturbing activity: County Brunswick City or Township Sunset Beach
Highway/Street Sunset Creek Way Latitude 33.9043 Longitude-78.4881
Approximate date land -disturbing activity will commence: April 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.42
Amount of fee enclosed: $ 600.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900,00).
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 J. Phillip Norris, P.E. E-mail Address [e-mail]
Telephone [phone] Cell# 910-471-9638 i=ax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Stan -lands Development, Inc. 919-606-5002 NIA
Name
7191 Gore Road
Current Mailing Address
Telephone
7191 Gore Road
Current Street Address
Ash NC 28420 Ash
City
10. Deed Book No.
419
State Zip City
Fax Number
NC 28420
State Zip
Page No. 127 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 orfrrm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Cranwood Sunset Beach, LLC [e-mail]
Name E-mail Address
381 Tanglewood Lane
Current Mailing Address
Bay Village OH
City
State
381 Tanglewood Lane
Current Street Address
44140 Bay Village
Zip City
Telephone [phone] Fax Number
OH 44140
State Zip
NIA

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 E-mail Address
3�A6 Lxvress
Current Mailing Address
5\•0.110�e_ NC Aiy 7& Csar
City State Zip
Telephoneq I D-'7 5ti- a 300
SI Ac) L Ss
Current Street Address
5VO-m0� .�7(yly 4,501
City State Zip
Fax Number I 0 -154 - 3
(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
E-mail Address
Current Street Address
City State Zip City
Telephone Fax Numb
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.
Thomas J. Charek
Type or pri e
Signature
Authorized Signatory
Title or Authority
—10 -?bZZ
Date
I, CL-0,4 , a Notary Public of the County of ��VrfL 1l L�
eta,State of hereby certify thatappeared
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 ION day of
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