NCC231759_FRO Submitted_20230607

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.
Depaitinent 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.
1. Project Name Moncure Valley Lots 9, 10, 11 and 12
2. Location of land-disturbing activity: County Lee City or Township Greenwood
Highway/Street Godwin Court Latitude_35.48959° Longitude -79.158843°
3. Approximate date land-disturbing activity will commence: January 26,2022
4. Purpose of development(residential,commercial, industrial,institutional, etc.): Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 3.19 acres
6. Amount of fee enclosed: $ 400.00 . 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).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Watson Caviness E-mail Address pj a,cavinessland.com
Telephone [phone] Cell# 910-237-0572 Fax# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Moncure Investments, LLC 910-339-6330 910-339-6333
Name Telephone Fax Number
1041 B Robeson Street 1041 B Robeson Street
Current Mailing Address Current Street Address
Fayetteville, NC 28305 Fayetteville, NC 28305
City State Zip City State Zip
10. Deed Book No. 1521 Page No. 525 Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(s) who are financially resp: isible 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.
Caviness Land Development,Inc. 910-339-6330 910-339-6333
Name Telephone Fax Number
1041 B Robeson Street 1041 B Robeson Street
Current Mailing Address Current Street Address
Fayetteville, NC 28305 Fayetteville, NC 28305 _
City State Zip City State Zip
Telephone [phone] Fax Number 910-339-6333

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Watson G. Caviness President
Type or print n e Title or Authority
s
12/29/2021
Signature Date
I, Lori Simpson Epler , a Notary Public of the County of Cumberland
State of North Carolina, hereby certify that Watson G. Caviness 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 29th day of December , 20 21
Notary Public
Leri Sirrsps®n Epler N ary
Sialbcrlan. County
North Carolina My commission expires 11/14/2024