NCC230120_FRO Submitted_20230113

:heck if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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
2.
3.
4.
5.
Project Name Townhomes at Scott's Hill
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
Location of land -disturbing activity: County Pender City or Township Hampstead
wa Hi h/Street Hwy 17 34.347-77.733
g y LatltUde(decimal degrees) LOngltUde(decimal degrees)
Approximate date land -disturbing activity will commence: 1 /16/2023
Purpose of development (residential, commercial, industrial, institutional, etc.): residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 17.4
6. Amount of fee enclosed: $ . 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:
Name Scott Hale E-mail Address [e-mail]
Phone: Office # 910-251-5030
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The Townhomes at Scott's Hill LLC 910-251-5030 910-777-4192
Name
332 Military Cutoff Rd
Current Mailing Address
Wilmington NC
City State
10. Deed Book No. 4765
Phone: Office # Mobile #
same
Current Street Address
28405
Zip City
Page No. 2244
State
Zip
Provide a copy of the most current deed.

Part B.
1. 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).
Tribute Investment & Development LLC
Company Name
332 Military Cutoff Rd
Current Mailing Address
Wilmington NC 28405
City State Zip
Phone: Office # 910-251-5030
[e-mail]
E-mail Address
same
Current Street Address
City State Zip
Mobile # [phone]
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City
Phone: Office #
State
Zip City
Mobile #
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.
04,
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
—%lLCi.Dm w
Engineering firm or other consultant
Ls c rAQ- s
Individual contact person (type or print)
art Ssr raAC�[t�rd 9 • �1
E-mail Address
h e: Office # Mobile #
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.
Type or print name J Title or Aut or ty
7
Signature Date
-------------------------------------------------------------------------------------------------------------------------
a Notary Public of the County of
State of North Carolina, hereby certify that Marv, 14AW 1 appeared personally
before me this day and being duly sworn acknowledged th6t the above form was executed by him/her.
Witness my hand and notarial seal, this 1 `, day of 20 a�
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Z 3 a My commission expiresa,s 3n?0�5
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