NCC221741_FRO Submitted_20220518

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.
1. Project Name Chambray at Carolina Colours
2. Location of land -disturbing activity: County Craven City or Township New Bern
Bayberry Park Drive 35.001438-76.993671
Highway/Street Latltude(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: 9/1 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.0
6. Amount of fee enclosed: $ 600.00 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kip Peregoy E-mail Address [e-mail]
Phone: Office # 252-636-3700 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Overlook Holdings, LLC 252-636-3700
Name Phone: Office # Mobile #
PO Box 3557 503 W. Thurman Road
Current Mailing Address Current Street Address
Cary, NC 27419 New Bern, NC 28562
City State Zip City State Zip
10. Deed Book No. 3183 Page No. 0671 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).
Overlook Holdings, LLC
Company Name
100 Matrix Drive 8000
Current Mailing Address
Cary, NC 27513
[e-mail]
E-mail Address
100 Matrix Drive 8000
Current Street Address
Cary, NC 27513
City State Zip City State Zip
Phone: Office # 919-677-8000 Mobile #
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:
Corporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Ave Suite 550 2626 Glenwood Ave Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Phone: Office # 252 636 3700
Kenneth Kirkman
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 chanqe in the information provided herein.
Kenneth M. Kirkman
Type or print name
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Vice President _
Title or Authority
Date
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)tayy Public of the County
State of North Carolina, hereby certify that //)J)
personally before me this day and being duly worn
executed by him.
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Witness my hand and notarial seal, this ` day _
SUZANNE VINCENT
NOTARY PUBLIC
CRAVEN COUNTY, INC Notary
Commission Expires B-15.2023
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