NCC240472_FRO Submitted_20240219

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Seven Lakes Country Club, Shropshire Section—Lot 2083 and Cambridge Section Lot 2312
2. Location of land-disturbing activity: County Moore_City or Township Mineral Springs Township
Devonshire Avenue W&
Highway/Street Winsford Circle Latitude(decimal degrees) N35.2602° Longitude(decimal degrees)W-79.5711°
3. Approximate date land-disturbing activity will commence: February 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.23 Acres
6. Amount of fee enclosed $200.00 Normal & 500 Express . The Express Permitting application fee is a
dual charge. The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a
ceiling amount. In addition, the Express Permitting supplement is $250 per acre up to eight acres,
after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre
application fee is $2,900). Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed Z No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Leanna Hair E-mail Address leannahaironsitehomesnc.com
Phone: Office# 910-745-0001 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Christopher Scott Hopkins 910-528-7212
Name Phone: Office# Mobile#
245 Devonshire Avenue W Same
Current Mailing Address Current Street Address
West End NC 27376 Same
City State Zip City State Zip
Lot 2083 Shropshire Section Lot 2083 Shropshire Section
10. Deed Book No. 6002 Page No. 440 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).
Onsite Homes, LLC nedjohnson(a�onsitehomesnc.com
Company Name E-mail Address
2931 Breezewood Avenue, Suite 202 Same
Current Mailing Address Current Street Address
Fayetteville NC 28303 Same
City State Zip City State Zip
Phone: Office# 910-745-0001 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:
Nathaniel Johnson nedjohnson(a�onsitehomesnc.com
Name of Registered Agent E-mail Address
2931 Breezewood Avenue, Suite 202 Same
Current Mailing Address Current Street Address
Fayetteville NC 28303 Same
City State Zip City State Zip
Phone: Office# 910-745-0001 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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Moorman, Kizer& Reitzel, Inc. [e-mail]
Engineering firm or other consultant E-mail Address
Dennis A. Gilbert 910-484-5191
Individual contact person (type or print) Phone: Office # Mobile#
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.
Nathaniel Johnson 1 Managing Member
Type or print name Title or Auth ity
i 1 zy
Signature 'f Date
I, Ti--aona
' 21/1pO �t,f�'� , a Notary Public of th County of aw,604aiti
State of North Carolina, hereby certify that )JC&IfD12 . ? 'U l appeared
personally before me this day and being duly sworn acknowledg that the above form was
executed by him/her. � r
Witness my hand and notarial seal, this day of I , 2 Zq
Notar
J4_
2-61 Z-gri
My co mis on expires

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:
Francis A. Guillen and Miguelina De Guillen 910-783-4797 910-315-1745
Name Phone: Office# Mobile#
954 Seven Lakes North Same
Current Mailing Address Current Street Address
West End NC 27376 Same
City State Zip City State Zip
Lot 2312 Cambridge Section Lot 2312 Cambridge Section
Deed Book No. 5988 Page No. 081 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:
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.