NCC221426_FRO Submitted_20220426

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 Blakefield Phase 7 Lots 254, 255 and 256
2. Location of land -disturbing activity: County Cumberland City or Township Cedar Creek Township
Highway/Street Croft Drive Latitude(decimal degrees) 35.027544 Longitude(decimal degrees)-78.764881
3. Approximate date land -disturbing activity will commence: April 05, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.83 acres
6. Amount of fee enclosed: $ 100.00 . The application fee of $100.00 per acre (rounded up to the
next acre) s assessed without a ceiling amour! (Example: 8.' 0-acre application fee is $900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ✓ Enclosed I '_ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ryan Hairr E-mail Address bridgeporthomesnc(o)-gmail.com
Phone: Office# 910-426-0867 Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners).
Bridgeport Homes, LLC _
Name
3077 N. Main St.
Current Mailing Address
Hope Mills NC 28348
City State Zip
910-426-0867 910-916-7589
Phone: Office # Mobile #
3077 N. Main St.
Current Street Address
Hope Mills NC 28348
City State Zip
10. Deed Book No. 11240 Page No. 005 Provide a copy of the most current deed.
Deed Book No. 11273 Page No. 513
Deed Book No. 11200 Page No. 197

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).
Bridgeport Homes, LLC
Company Name
3077 N. Main St.
Current Mailing Address
bridge porthomesnc(o),gmail. corn
E-mail Address
3077 N. Main St.
Current Street Address
Hope Mills NC 28348 Fayetteville NC 28348
City State Zip City State Zip
Phone: Office # 910-426-0867 Mobile # [phone]
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #

Name of Individual to Contact (if Registered Agent is a company)
(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.
Jackie Hairr
Type or print nam
Signature
Managinq Member
Title or Authority
03/22/2022
Date
1, "'OP ( 51 Y7 t ���'.5 �'GE� a Notary Public of the County of On 6fXC e/ Icy
State of North Carolina, hereby certify that J �CK1 14A 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 2 ,2— day of l%'L 20
Notary public Notary _
Lori Simpsom Epler
My commission expires
Cruberlaal. Calaty
North Ca as