NCC222082_FRO Submitted_20220623

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 NIA in the blank.)
Part A. Albemarle Preserve - Phase 1 A
1. Project Name
2. Location of land -disturbing activity. County Perquimans City or Township Bethel
Highway/Street Harvey Point Rd. Latitude 36.109 Longitude-76.374
3. Approximate date land -disturbing activity will commence: April 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 100.00
6. Amount of fee enclosed: $ 10,000.00 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Woody Perry E-mail Address [e-mail]
Telephone Cell # 757-869-0001 Fax #
0]
Landowner(s) of Record (attach accompanied page to list additional owners):
Perquimans Holdings, LLC 678-782-8465
Name Telephone Fax Number
11675 Rainwater Dr., Ste 220 1675 Rainwater Dr., Ste 220
Current Mailing Address Current Street Address
Alpharetta GA 30009 Alpharetta GA 30009
city
10. Deed Book No. 495
State
Zip City
Page No. 149
State
�'
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.
Perquimans Holdings, LLC
Name E-mail Address
1675 Rainwater Dr., Ste 220 1675 Rainwater Dr., Ste 220
Current Mailing Address Current Street Address
Alpharetta GA 30009 Alpharetta GA 30009
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:
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:
Robert Masters bobby. [e-mail]
Name of Registered Agent E-mail Address
7900 Flip Flop Lane 7900 Flip Flop Lane
Current Mailing Address Current Street Address
Wilmington NC 28409 Wilmington NC 28409
City State Zip City State Zip
Telephone [phone]
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.
Robert Masters Registered Agent
Ty or print name Title or Authority
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Signature Date
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i, S: �_ L E is vh C _ I I a Notary Public of the County of _ �,J 146 m'' U_er
State of North Carolina, hereby certify that R'3 4 MO& r4r S appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. f 47
Witness my hand and notarial seal, this day of 20 c<o�
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