NCC232426_FRO Submitted_20230811

Corn3i ao a74
FINANCIAL RESPONSIBILITY/OWNE SHIP 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 bCEIVED
Part A.
1. Project Name Currin Hills Lots 1, 2, 4, 5, 17, 18 and 21 DEC 2 2021
2. Location of land-disturbing activity: County Cumberland City or Township Carvers Creek
Fayetteville Regional ()flirt-.
Highway/Street Nairn St Latitude 35.198496° Longitude -78.870523
3. Approximate date land-disturbing activity will commence: January 05, 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.39 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$900.00).
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 Benjamin Stout E-mail Address ben(7a benstoutconstruction.com
Telephone [phone] Cell# 910-476-4502 Fax# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Benjamin Stout Real Estate Services,Inc. 910-779-0019 910-779-0029
Name Telephone Fax
PO Box 53798 1786 Metromedical Drive
Current Mailing Address Current Street Address
Fayetteville NC 28305 Fayetteville NC 28305
City State Zip City State Zip
10. Deed Book No. 11331 Page No. 61 Provide a copy of the most current deed
Deed Book No. 11331 Page No. 72 ;Deed Book No. 11331 Page No. 122
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.
Benjamin Stout Real Estate Services,Inc. ben(abenstoutconstniction.com
Name E-mail Address
PO Box 53798 1786 Metromedical Drive
Current Mailing Address Current Street Address
Fayetteville NC 28305 Fayetteville NC 28305
City State Zip City State Zip
Telephone [phone] 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:
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.
Benjamin Stout President
Type or i name Title or Authority
Signature\ I Date (7,(zir lzotA
I, Wei 91MPeOPL MEP) , a Notary Public of the County of GdrnI N,D
State of North Carolina, hereby certify that 4 /'nif l*
' ll(,(,{'appeared personally before me this
day and being duly sworn acknowledged that the ibove form was executed by him.
Witness my hand and notarial seal, this 23 ro1 day of D9Cetriger , 20 21
' •
Notary Public
Lori Simpson Eplsr ota
i Cttithallani Connty
North Carolina My commission expires 1)• 14- 14