NCC222045_FRO Submitted_20220531

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 Environment and Natural Resources. (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 Name The Clubhouse at Coastal Estates (formerly Jensen's Coastal Plantation Clubhouse)
2. Location of land -disturbing activity: County_Pender_ City or Township_Hampstead
Highway/Street—NC HWY Route 17_ Latitude 34°22'43" N_ Longitude 77°41'50" W
3. Approximate date land -disturbing activity will commence: April 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.62
6. Amount of fee enclosed: $ 130 (sent prior) . 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 $585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Alex Adekova, PE E-mail Address aadekoyaa-wkdickson.com
Telephone [phone] Cell # Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Sun Coastal Plantation, LLC
Name
_531 Loblolly Trail
Current Mailing Address
_Hampstead NC 28405_
City State Zip
Telephone
Current Street Address
City
State
Fax Number
Zip
10. Deed Book No. 4697 Page No. 151-158 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Sun Coastal Plantation, LLC wpaxtonasuncommunities.com
Name E-mail Address
27777 Franklin Rd, Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Southfield MI 48034 Raleigh NC 27615
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:
Robert Erickson
Name E-mail Address
531 LobIgIly Trail _
Current Mailing Address
Hampstead NC 28405
City State Zip
Telephone [phone]
Current Street Address
City State Zip
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
Parry is a Corporation, give name and street address of the Registered Agent:
National Registered Aqents, Inc.
Name of Registered Agent
160 Mine Lake Ct Ste 200
Current Mailing Address
Raleigh NC 27615
city State Zip
Telephone
E-mail Address
Current Street Address
Raleigh NC 27615
City State- Zip
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 individua[
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.
Westley Paxton
Type or pri na
Signature
Vice President Construction Operations
Title or Authority
AC �7 ?'i Z 2_
Date
Notary Public of the County of
t Y1 i �/
State of i _ � ereby certify thatAappeared
personally before me this day and being duly sworn bicknowledged that the above form was
executed by him_
Witness my hand and notarial seal, this 1 l '
ROSANA a HYDER
NOTARY PUBLIC
r�� ��IWE:ALTFI OF VIRGINIA
^,i�A�IThT 9ON EXPIRES DEC
31. 2A
^e)Mto,19SION # 7929561
day of MCA" , 20
Notary My commission expires �/ 2 . ,ram J�