NCC230069_FRO Submitted_20230111

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.
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Project Name New Hope Place Apartments
Location of land -disturbing activity: County Wayne City or Township Goldsboro
Highway/Street Cuyler Best Road Latitude 35.394711 Longitude-77.939888
Approximate date land -disturbing activity will commence: July, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.3
Amount of fee enclosed: $ 600 The application fee of $100.00 per acre (rounded up to the
next acre) is assessed without a ceiling amount (Example: a 8.1-acre application fee is $900).
Has an erosion and sediment control plan been filed? Yes X No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jennifer Surber -New Hope Place, LLC
Telephone
Cell #
E-mail Add resslensurber(aDsurberdev.corn
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Robert Gambella
Name Telephone Fax Number
502 Greenbrier Circle Road
Current Mailing Address Current Street Address
Goldsboro NC 27534
City
State Zip City
State Zip
10. Deed Book No. RE 3720 Page No 422-446 Provide a copy of the most current deed. *Attached
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):
New Hope Place, LLC
Name E-mail Address
38 Green Tree Circle Road
Current Mailing Address Current Street Address
Bristol VA 24201
City State Zip City State Zip
Telephone 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:
David
Name
E-mail Address
507 West Peace Street
Current Mailing Address Current Street Address
City
NC 27603
State Zip City
Telephone [phone] Fax Number
State Zip
(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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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 information should there be any change in the information provided herein.
Jennifer Surber Managing Member
Type or print name Title or Authority
Signature Date s
a Notary Public of the County of0
State of North Carolina, hereby certify that -51waar appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my han�q,R{A,pQarial seal, this day of AW \ , 20 _
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