NCC223519_FRO Submitted_20221013

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 Cedar Hill #2
2. Location of land -disturbing activity: County Jackson City or Township Cashiers
Highway/Street Mila Springs Road Latitude 35.1116503 Longitude-83.0635
3. Approximate date land -disturbing activity will commence: 6/1/22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.95
6. Amount of fee enclosed: $ . 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
8, Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tim O'Neil E-mail Address [e-mail]
Telephone [phone] Cell # same Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Caryn & Steve Silver 941-504-8079 n/a
Name Telephone Fax Number
1500 Shelburne Lane same as mailing
Current Mailing Address Current Street Address
Sarasota FL 34231
City State Zip City State Zip
10. Deed Book No, 2336 Page No, 1043 Provide a copy of the most current deed.
Part B.
1. 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):
Loudermilk Homes, LLC [e-mail]
Name E-mail Address
1827 Powers Ferry Rd, SE same as mailing
Current Mailing Address Current Street Address
Atlanta GA 30339
City State Zip City State Zip
Telephone [phone] Fax Number 800-594-1094

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:
Monika Pol
Name
1827 Powers Ferry Rd, SE
Current Mailing Address
Atlanta
City
GA 30339
State Zip
[e-mail]
E-mail Address
same as mailing
Current Street Address
City State Zip
Telephone [phone] Fax Number 800-594-1094
(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:
Monika Pol
Name of Registered Agent
[e-mail]
E-mail Address
1827 Powers Ferry Rd, SE same as mailing
Current Mailing Address Current Street Address
Atlanta GA 30339
City State Zip
City
Telephone 770-4$5-2600 Fax Number 800-594-1094
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.
Mof1bC�V� �i S'S10►A��
Type or print name Title or Authority
to IAA
Signatur Date
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I, Wars a Notary Public of the County of 3WL&5A-
State of North Carolina, hereby certify that li I, 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 W day of b &bbtX , 20�
I'aia4 a-. %W4
NEARY A SELLERS Nota
LNotmarry Pt8& North Carolina \
Jackson County 1� 2�
ission Expires Jun 5, 2027 My commission expires VVV I