NCC221658_FRO Submitted_20220428

NT21152-1
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. Carolina Estates
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Shallotte
Highway/Street US 17 Latitude 33.94550 Longitude-78.5361 °
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): 38.5
B. Amount of fee enclosed: $ Previously Paid 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 x No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Joseph K. Bland, P.E.
Name
E-mail Address [e-mail]
Telephone [phone] cell # 910-512-8148 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Lennar Carolinas, LLC
[phone] N/A
Name
Telephone Fax Number
700 N.W. 107th Avenue, Suite 400
700 N.W. 107th Avenue, Suite 400
Current Mailing Address
Current Street Address
Miami FL 33172-3139
Miami FL 33172-3139
City State Zip
City State Zip
10. Deed Book No.4776/4776 Page No.
3141712 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.
Lennar Carolinas, LLC
[e-mail]
Name
E-mail Address
700 N.W. 107th Avenue, Suite 400
700 N.W. 107th Avenue, Suite 400
Current Mailing Address
Current Street Address
Miami FL 33172-3139
Miami FL 33172-3139
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:
Corporate Creations Network, Inc.
Name
1.5720 Brixham Hill Ave. #300
E-mail Address
15720 Brixham Hill Ave. #300
Current Mailing Address Current Street Address
Charlotte NC 28277 Charlotte NC 28277
City State Zip City State Zip
Telephone 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 E-trail Address
Current Mailing Address Current Street Address
City State Zip 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 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.
Gabe Ebner Vice President
Type or
WOM
i
Title or Authority
Z ,15.27-
Date
I, Tt,gak_ TA Ew , a Notary Public of the County of _ k&A_ -eW--
�o
State of Carolina, hereby certify that 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 day of �r-_
t�JO , 20 22.
X /AA���
Notary
My commission expires 'L-11-ZOZ�