NCC221062_FRO Submitted_20220316

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. Beau Coast Phase 4
1. Project Name
2. Location of land -disturbing activity: COUnty Carteret City or Township Beaufort
Highway/Street_
Brown Pelican Way Latitude Longitude 340 43' 04" 760 37' 59"
3. Approximate date land -disturbing activity will com
4
Upon Receiving Permit
Purpose of development (residential, commercial, industrial, institutional, etc.) Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12.41
6. Amount of fee enclosed: $ 1,300 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 Karl Blackley E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Blue Treasure, LLC/Sunken Treasure, LLC [phone] N/A
Name
105 Weston Estates Way
Current Mailing Address
Cary NC
City State
10. Deed Book No. 1256
Telephone Fax Number
I65, -9 'Weston Estates Way
Current Street Address
27513 Cary NC
Zip City State
198
27513
Zip
Page No. 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.
Blue Treasure, LLC [e-mail]
Name E-mail Address
105 Weston Estates Way lay IQMeston Estates Way
Current Mailing Address Current Street Address
Cary NC 27513 Cary NC 27513
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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 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
Telephone
E-mail Address
Current Street Address
Zip City
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.
-MAVII/ VoAgftl�
-
Title or Authority
/- 02 r- aZ
Date
i a Notary Public of the County of
State of North Carolina, hereby certify that 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 T;%y of
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My commission expires QZ