NCC221191_FRO Submitted_20220404

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 N/A in the blank.)
Part A.
1. Project NameCatherine's Way
2. Location of land -disturbing activity: County Ot1SlOW T City or Township
Catherine Lake -77 5214
Highway/Street Road Latitude 34.8175 Longitude—.7
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):. _21.1 _
6. Amount of fee enclosed: $ 2,200 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 WS).
7. Has an erosion and sediment control plan been filed? Yes______ _ No_. X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:.
Name Dominick Butch E-mail Address [e-mail]
Telephone_ [phone]Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Lighthouse Realty Holdings, LLC [phone] _
Name Telephone Fax Number
814 New Bridge Street Suite D 814 New Bridge Street Suite D
Current Mailing Address Current Street Address
Jacksonville, NC 28540 Jacksonville, NC 28540
city State Zip City 'State —� Zip
10. Deed Book No. 5418 Page No. 815 Provide a copy of the most current deed.
Part B.
1. Company (iss) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) Jf the company or firm is a sole
prQprieft"hip the name of the owner or manager may be listed as the financially responsible patty.
Lighthouse Realty Holdings, LLC [e-mail]
Name _ E-mail Address
814 New Bridge Street Suite D 814 New Bridge Street Suite D
Current Mailing Address Current Street Address �—
Jacksonville, NC 28540 Jacksonville, NC 285.40
City State Zip City State Zip

Telephone [phone] 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 State Zip
Telephone _
E-mail Address
Current Street Address
City State
Fax Number r_.__ _
Zip
(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
Telephone_
E-mail Address
Current Street Address
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.
Dom#nick Butch Owner ma nay e v
ZIT7nt na Title or Authority
A •v,
Signature Date
1, 2ja j,r T a Notary Public of the County of 1 /u PL'LAL
State of North Carolina, hereby certify that 1 m t C l< ",�y t iaC appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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Witness my hand and notarial seal, this 1_ day of r�BPu�2 y 20�
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My commission e it _ 7
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