NCC240354_FRO Submitted_20240212

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Deep River East Phase 2
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Lee City or Township Sanford
Highway/Street: SR1403 Latitude(decimar degrees) 35.545 Longitude(decimai degrees) -79.236
3. Approximate date land-disturbing activity will commence: Spring 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 32.00 AC
6. Amount of fee enclosed: $ 3,200.00 . 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 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Josh Spiegel E-mail Address iosh.spiegel(a)Igihomes.com
Phone: Office# 980-722-0391 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
LGI Homes NC, LLC 980-722-0391
Name Phone: Office# Mobile#
6500 Creedmoor Road, Suite 212 same
Current Mailing Address Current Street Address
Raleigh, NC 27613 same
City State Zip City State Zip
10. Deed Book No. 1651 Page No. 408-413 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)maybe listed as the financially responsible party(ies).
LGI Homes NC, LLC XXX
Company Name E-mail Address
6500 Creedmoor Road, Suite 212 same
Current Mailing Address Current Street Address
Raleigh NC 27613 same
City State Zip City State Zip
Phone: Office# 980-722-0391 Mobile# [phone]
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:
Josh Spiegel iosh.spiegelAlgihomes.com
Name of Registered Agent E-mail Address
5511 Capital Center Dr, Suite 560 _same
Current Mailing Address Current Street Address
Raleigh NC 27613 same
City State Zip City State Zip
Phone: Office# 980-722-0391 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.
Josh Spiegel Authorized Officer
Type or print name Title or Authority
,5'ef:71 8.10.2023
_Signature Date
A `S-C\LA , a Notary Public of the County of Via ICL
State of North Carolina, hereby certify that X-)S\--._ 1'l)C ( appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her. --�
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Witnes oh � 'Y�tarial seal, this /6 day of /4 /S t , 20 2 5
(0/ oTAii)LvA
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expires ('' .• „ W/ Continued from Items 9 & 10 in Part A of the Financial
Responsibility/Ownership Form for multiple owners. Attach copies of this page as needed to list all
landowners.
Landowner 2 of Record:

Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
1
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Continued from Item 'I in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.

Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
j Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
[ City State Zip City State Zip
Phone: Office# Mobile#
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