NCC222299_FRO Submitted_20220622

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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.
1. Project Name Griffon Pointe Subdivision - Phase 1
2. Location of land -disturbing activity: County Harnett City or Township Upper Little River Township
Highway/Street (SR 1291) Old US 421 Latitude N35.403889 Longitude W78.860331
3. Approximate date land -disturbing activity will commence: August/September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.00 acres
6. Amount of fee enclosed: $1 260.00 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Braxton Montague E-mail Address [e-mail]
Telephone [phone]
cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Tierra Holdings, LLC
[phone]
Name
Telephone Fax Number
10305 Penny Road
10305 Penny Road
Current Mailing Address
Current Street Address
Raleigh, NC 27606
Raleigh, NC 27606
City State
Zip City State Zip
10. Deed Book No. 3974
Page No. 232 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Tierra Holdings, LLC.
[e-mail]
Name
E-mail Address
10305 Penny Road
10305 Penny Road
Current Mailing Address
Current Street Address
Raleigh, NC 27606
Raleigh, NC 27606
City State
Zip City State Zip
[phone]
Telephone
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:
Name E-mail Address
Current Mailing Address Current Street Address
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:
Sherri Montague
[e-mail]
Name of Registered Agent
E-mail Address
10305 Penny Road
10305 Penny Road
Current Mailing Address
Current Street Address
Raleigh, INC 27606
Raleigh, NC 27606
City State Zip
City State Zip
Telephone [phone]
Fax Number
(c) In order to facilitate Express Permitting, it
is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Carolina Land Development Group, Inc.
[e-mail]
Engineering Firm or other consultant
E-mail Address
Spencer B. Terry III, PE
[phone]
Individual contact person (type or print)
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.
Sherri Montague
iypA or print name
ature
Registered Agent
Title or Auth ity
Date
a Notary Public of the County of Wa c-e_
State of North Carolina, hereby certify that Sev i rrf� w e— appeared personally
before me this day and being duly sworn acknowledged that the a ove form was executed by him.
Witness my hand and notarial seal, this e
Ellen M. Haynes
NOTARY PUBIC
County
North Carolina
My Gommission EKp ees June 11. 2023
day of OC-4060e— , 20 -)'1
Notary
My commission expires e 1! 0 2 3