NCC224039_FRO Submitted_20221207

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Heartsease at Calabash
2. Location of land -disturbing activity: County Brunswick City or Township Calabash
Persimmon Road (SR 1167) 33.9055-78.5702
Highway/StreetLatltude(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: Upon receipt Of permit
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)- NA
6. Amount of fee enclosed 5 NA The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameAndy Smith E-mail Address andy 9 eyccom pan ies
Phone: Office # 843.588.5021 Mobile # NA
9 Landowner(s) of Record (attach accompanied page to list additional owners):
Heartsease Calabash, LLC 843.588.5530 NA
Name
6837 Falls of Neuse Road, Suite 208
Current Mailing Address
Raleigh,
City
10. Deed Book No. 4923
Phone: Office # Mobile #
6837 Falls of Neuse Road, Suite 208
Current Street Address
NC 27615 Raleigh, NC 27615
State Zip City
Page No. 0766
State
Zip
Provide a copy of the most current deed.

Part B.
I- Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Heartsease Calabash, LLC
Company Name
6837 Falls of Neuse Road, Suite 208
Current Mailing Address
Raleigh, NC 27615
City State
Phone: Office # 843.588.5530
andy@eyccompanies
E-mail Address
6837 Falls of Neuse Road, Suite 208
Current Street Address
Raleigh, NC 27615
Zip City
Mobile # NA
State
52
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Heartsease Calabash, LLC [e-mail]
Name of Registered Agent E-mail Address
6837 Falls of Neuse Road, Suite 208 6837 Falls of Neuse Road, Suite 208
Current Mailing Address
Raleigh, NC 27615
City State Zip
Current Street Address
Raleigh, NC 27615
City
Phone: Office # 843.588.5530 Mobile # NA
Ellis Coleman
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
NA
Name of Registered Agent
NA
Current Mailing Address
NA
City
Phone: Office # NA
NA
NA
E-mail Address
NA
Current Street Address
NA
State Zip City
Mobile # NA
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
NA
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Ellis Colem
Type or prin
Sig
Principal
Title or Authority
s D2
Date or
I, S a Notary Public of the County of C
State of North Carolina, hereby certify that �- [�L�'��appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this -`day of , 20 '2- —2�
SARAH NIENHAUS
Notary Public, State of South Carolina
My Commisslon Expires 2/10/2026 NoWy
My commission expires �� 2�