NCC230760_FRO Submitted_20230321

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. Beau Coast Phase 3
1. Project Name
2. Location of land -disturbing activity: County Carteret City or Township Beaufort
Highway/Street Freedom Park Road Latitude 34.720289 _ Longitude-76.641263
3. Approximate date land -disturbing activity will commence. Upon Receiving Permit
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 18.5
6. Amount of fee enclosed: $ 1,900 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
& Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Karl Blackley E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax # N/A
7
Landowner(s) of Record (attach accompanied page to list additional owners):
Blue Treasure, LLC [phone] N/A
Name Telephone Fax Number
105 Weston Estates Way 105 Weston Estates Way
Current Mailing Address
Cary NC 27513
City State
10. Deed Book No. 1256
Current Street Address
Cary NC 27513
Zip City
Page No. 198
State
Zip
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.
Blue Treasure, LLC [e-mail]
Name
105 Weston Estates Way
Current Mailing Address
Cary NC 27513
City State Zip
Telephone [phone]
E-mail Address
105 Weston Estates Way
Current Street Address
Cary NC 27513
City State Zip
Fax Number N/A

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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City
Telephone N/A
State Zip
City
Fax Number N/A
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:
N/A N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City State Zip
Telephone N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Fax Number N/A
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.
Julian Rawl
Type print na
ature
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Member Manager
Title or Authority
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Date
I, V 1 ;'� E_ I Mbh J , a Notary Public of the County of K-e
State of North Carolina, hereby certify that V11 I dl11 rV tkj 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 IS
day off J� 20 p
Notary rl�—-
My commission expires S ULj 1 `1 �Jh VP