NCC215228_FRO Submitted (Recovered)_20210916

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 acoeptable 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.
I. Project Name Laurel R ivi ' n 11-ots # 29,39.4Q.41)
2. Location of land -disturbing activvity: County_ Moore City or Township _Mineral Springs
Highway/Stra$ Pine LAWX1 Drnre Latitude 35.2509 _. Longitude-79.4411
3. Approximate date land -disturbing activity will commence: As soon as possible
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_ 1.91
6. Amount of fee enclosed: $ 130.40 . 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 erasion and sediment control plan been filed? Yes No Enclosed V
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Pamela Gesldie E-mail Address Ramftcavim sandcates.com
Telephone [phone] Cell # [phone] Fax # [phone]$5
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Caginess (910) 78-7902 1910) 481-0585
Name Telephone Fax Number
639 Executive Place, Suite 400 Same
Current Mailing Address. Current Street Address
Favettev{lle N.C. 28305 Same
City State Zip City State Zip
10. Deed Book/Page No. Bk Pa Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(a) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the oo1np9ny or firm is a sole
propdatorship the name of the owner or manager may be Hated as the financially fesponstble party.
Caviness & C uil"I Developmeal Co. chrisi ftavinessandcates.com
Name E-mail Address
Place, Suite400 Same
Current Mailing Address Current Street Address
EavMville N.C. 26305 Same
City state zip City state Zip
Telephone [phone] Fax Number i910) 481-0585

Z. (a) If the Financially Responsible Patty 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 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
State Zip
E-mail Address
Current Street Address
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 Penton 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.
ChrisMRher E. Cates
Type or print name
Sigr kure
Vice President
Title or Authority
1'Y II LO� q, bod l
Date
I,( /I —)a �.F - a),i[;,} edd , a Notary Public of the County of be'(&W I
State of North Carolina, hereby certify, that ,CkOak appeared
personally before me this day and being duly sworn ackn wledged that the above form was executed
by him.
Witness my hand and
Seal '- z'
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