NCC222471_FRO Submitted_20220711

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Danish Drive Townhomes
1. Project Name
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street Danish Drive Latitude 35.105778 Longitude 79.004022
3. Approximate date land -disturbing activity will commence: December 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.69 aC
6. Amount of fee enclosed: $ 195.00 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Raymond King E-mail Address kingconst201 [e-mail]
Telephone [phone] cell # 910-237-0932 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
King Construction & Development Company, Inc 910-424-3119
Name Telephone Fax Number
8736 King Road
Current Mailing Address Current Street Address
Fayetteville, NC 28306
City State Zip City State Zip
10. Deed Book No. 11176 Page No. 395 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.
King Construction & Development Company, Inc [e-mail]
Name E-mail Address
8736 King Road j►. SAME
Current Mailing Address Current Street Address
Fayetteville, NC 28306
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 Parry 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-mail 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 infor ation should there be any change in the information provided herein.
Type or printame Title or Aut ority
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Signature Date
I, �ifV a Notary Public of the County off
State of North .Carolina, hereby certify that �I l 1►x►�� K.yk'l h n� appeared
personally ' before me this day and being duly sworn ackno ledged that the above form was
executed by him.. „
day of 20oll
Witness my hand 6r�¢�totaril seal, this y
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Notary
Seal )2P.�
My commission expires �
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