NCC223140_FRO Submitted_20220906

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 N/A in the blank.)
Part A. Park Meadows Phase II - Building2
1. Project Name
2. Location of land -disturbing activity: County.Unlon City or Township Indian Trail
Hi.ghway/Street 3801 Old Monroe Rd Latitude 35.07456037853149 Longitude-80.68475389779967
3. Approximate date land -disturbing activity will commence:August 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.: Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.32
6. Amount of fee enclosed: $ $ 1 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:
blame Marwan Shahin E-mail Address [e-mail]
Telephone [phone] cell #� Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Park Meadows Development, LLC
Name Telephone Fax Number
231 Post Office Drive, Suite B8
Current Mailing Address Current Street Address
Indian Trail, NC 28079
City State Zip City State Zip
10, Deed Book No. 7194 Page No, 280 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 companyorfirm is a sate proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
H&H Constructors of Fayetteville, LLC [e-mail]
Name
E-mail Address
2411 Robeson Street, Suite 200
Current Mailing Address Current Street Address
Fayetteville, NC 28305
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:
nla
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zrp
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:
Jay C Lewis, II
Name of Registered Agent E-mail Address
8601 Six Forks Rd Forum 1, Suite 220 8601 Six Forks Rd Forum 1, Suite 220
Current Mailing Address Current Street Address
Raleigh NC, 27615 Raleigh NC, 27615
City
State
Zip
City
Telephone [phone] Fax Numbe
State Zip
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.
Marwan Shahin
Ty r print na ie
Signature
Vice President, Land
Title or Authority
7/28/2022
Date
(—UC)O a Notary Public of the County ot_RDM&n
State of North Carolina, hereby certify that Marwan Shahin appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 28 day of July
h Kelly Moore
eI'`A Notary Public
ry :•m Rowan County, NC
2022
Ow
Notary
My commission expires lot -a