NCC221343_FRO Submitted_20220406

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
Project Name Bedford Subdivision Section 5
2. Location of land -disturbing activity: County Hoke City or Township_ McLauchlin
Highway/Street_US Hwy 401-Bedford Dr Latitude(decimal degrees)N35.0414 Longitude(decimai degrees)W79.1307
Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 45.99
6. Amount of fee enclosed: $ 4600 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed Z No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Michael Kaney E-mail Address michaelkamikam4mtsolns.com
Phone: Office # 919-917-7298 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pelican Property Holdings, LLC
Great Oaks Progeny Holdings, LLC. 910-864-3135
Name Phone: Office #
238 North McPherson Church Rd
Current Mailing Address
Current Street Address
Mobile #
Fayetteville NC 28303
City State Zip City State Zip
10. Deed Book No... 982 Page No. 496 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
H&M Bedford LLC
Company Name
4208 Six Forks Road, Suite 810
Current Mailing Address
Ralei h NC 27609
City State Zip
Patmckeehomesnc.com _
E-mail Address
Current Street Address
City
Phone: Office # 919-793-5237 Mobile #
State
Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Cooencv Global Inc.
Name of Registered Agent
212 South Tryon Street Suite 1000
Current Mailing Address
Charlotte NC 28281-0001
City State Zip
Phone: Office # 866-775-0114
twallace�7a cogenc lobal.com
E-mail Address
Current Street Address
City State Zip
Mobile #
Jori Wallace
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # _ Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Patrick McKee
Type ppont name
Signature
Member, H&M Bedford, LLC.
Title or Authority
3) -
Dat
I, 'D an(4Y"G 1` -Cri e l , a Notary Public of the County of ( 4,mherlCcnd
State of North Carolina, hereby certify that wA-� C�- 'YG k e _ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her-
Witness my hand and notarial seal, this day of mof- n , 200,'�
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Rp, BE/y
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Seal
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Notary
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