NCC232697_FRO Submitted_20230912

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. K ndall Cove
1. Project Name y
2. Location of land-disturbing activity: County Brunswick City or Township Leland
Highway/Street Old Fayetteville Road Latitude 34.237363 Longitude-78.020741
3. Approximate date land-disturbing activity will commence:September 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):39.70
6. Amount of fee enclosed: $ 4,000 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
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Michael J. RokoWski E-mail Address [e-mail]
Telephone [phone] Cell# 910-315-6200 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Fay-Fieldcrest LLC
Name Telephone Fax Number
PO Box 1328 Old Fayetteville Road
Current Mailing Address Current Street Address
Wrightsville Beach NC 28480 Leland NC 28451
City State Zip City State Zip
10. Deed Book No.04668 Page No.0649 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.
Fay-Fieldcrest LLC [e-mail]
Name E-mail Address
PO Box 1328
Current Mailing Address Current Street Address
Wrightsville Beach NC 28480
City State Zip City State Zip
Telephone [phone] Fax Number

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 rson)___I agree to provide
corrected information should there be any change in th inf tr n ovi ed hen.
(CLIAGG �. RO OCrV—I A/N
Type or int name — % Titltor AtlihOrity
41t3 /ze-
ignatur Date
a[A vg V 1Ot V of V 1 1wv , a Notary Public of the County of N. hQYOUe V
State of North Carolina, hereby certify that MDitIO • ,D'vV 1 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 of dor& , 20 11
Laura Victoria Mellor a4 9/4&(--f9/
Notary Public otary
New Igver County, NC
My Commission Expires 0310612027 My commission expires D - DL0• 2-0 2.7