NCC223849_FRO Submitted_20221118

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. Jarvis Landis
1. Project Name g
2. Location of land -disturbing activity: County Currituck City or Township JaryiSburg
Highway/Street Jarvis Landing Dr Latitude 36.17958 Longitude-76.86533
3. Approximate date land -disturbing activity will commence: October 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7
6. Amount of fee enclosed: $ 700.00 . 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 Peter Kauffman E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
GOB, LLC [phone]
Name Telephone Fax Number
4300 S. US Highway 1 Suite 203-346 4300 S. US Highway 1 Suite 203-346
Current Mailing Address Current Street Address
Jupiter FL 33477 Jupiter FL 33477
City State Zip City State Zip
10. Deed Book No.1047 Page No. 828 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.
4300 S. US Highway 1 Suite 203-346
Current Mailing Address
Jupiter FL 33477
City
State Zip
[e-mail]
E-mail Address
4300 S. US Highway 1 Suite 203-346
Current Street Address
Jupiter FL 33477
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:
Desiree Anderson
[e-mail]
Name
E-mail Address
PO Box 370
2522 S. Croatan Hwy Suite 1 C
Current Mailing Address
Current Street Address
Kill Devil Hills NC 27948
Nags Head NC 27959
City State Zip
City State Zip
(252jx4ny �
Fax Number
Telephone [phone]
(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
Parry is a Corporation, give name and street address
of the Registered Agent:
Desiree Anderson
[e-mail]
Name of Registered Agent
E-mail Address
PO Box 370
2522 S. Croatan Hwy Suite 1 C
Current Mailing Address
Current Street Address
Kill Devil Hills NC 27948
Nags Head NC 27959
City State Zip
City State Zip
(2%bY47A3XW4
Fax Number
Telephone [phone]
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.
Peter J. Pintq,7 Manager
Typ�-pr p
Signature
Title or Authority
r.3. 2,DZZ-
Date
I, i`�L SG� 1 a Notary Public of the County of Oaf
State of North Carolina, hereby certify thatLV� 1� �1�� 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 Isd day of ��eO� 20
Karyn R Stafford
"RY PUBLIC
Dare County, NC
My Commission Expires September 30, 2026
jog;ia��
Notary
My commission expires `(�L�.T �� �Cp