NCC232400_FRO Submitted_20230908

NT#23037
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Oak Harbor Village
2. Location of land-disturbing activity: County Brunswick City or Township Bolivia
Sunset Harbor Rd.SE/Southport-Supply Rd.W 985 -78.189
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence:January 1 , 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 20
6. Amount of fee enclosed: $2,000.00 . 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).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name J. Phillip Norris, P.E. E-mail Address [e-mail]
Phone: Office# 910-287-5900 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Oak Harbor Residential, LLC 216 464-2860
Name Phone: Office# Mobile#
629 Euclid Avenue Suite 1300 629 Euclid Avenue Suite 1300
Current Mailing Address Current Street Address
Cleveland OH 44114-3003 Cleveland OH 44114-3003
City State Zip City State Zip
10. Deed Book No.4927/4927 Page No. 1 158/1161 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).
Oak Harbor Residential, LLC [e-mail]
Company Name E-mail Address
629 Euclid Avenue Suite 1300 629 Euclid Avenue Suite 1300
Current Mailing Address Current Street Address
Cleveland OH 44114-3003 Cleveland OH 44114-3003
City State Zip City State Zip
Phone: Office# 216-464-2860 Mobile#
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:
COGENCY GLOBAL INC.
Name of Registered Agent E-mail Address
212 South Tryon Street Suite 1000 212 South Tryon Street Suite 1000
Current Mailing Address Current Street Address
Charlotte NC 28281 Charlotte NC 28281
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 State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(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.
Company DBA Name
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.
Brian Midlik Vice President
Type dint name Title or Authority
7/Sl Boa 3
Signature Date
I, coil* BL'f kSIC ,allotary Public of the County of Cvy4{f 0
OH io
State of Plerth-C-relina, hereby certify that T3/LI4N M i b L.J lc appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this S day of , 20 e 3
`4, T sy DANIELE BETLISKEY /1/ „
01 Notary Public Notary
,x. o My Comm.Expires
ro '''"•`f9 June 24,2025 My commission expires 02 L/, 0?0.25