NCC240670_FRO Submitted_20240307

August 16, 2023
To Whom It May Concern:
NCDEQ, Division of Energy, Mineral and Land Resources
225 Green Street, Suite 714
Fayetteville,N.C. 28301-5043
I, fC/" A- ,member of AGS LAND,LLC, am the owner of the Collier Gate
Estates Subdivision as shown on Plat Book 150, Page 001 in the Cumberland County, North
Carolina Registry. I do hereby grant permission to JSJ Builders, Inc.to apply for lot erosion and
sedimentation control permits said property. JSJ Builders, Inc.. will be financially responsible for
any land disturbing activity on the lots during the work that encompasses this project.
AGS LT7LLCN
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Date
STATE OF NOPT'H CAROL E A
COUNTY OF :,e °: ;'•
I certify that terk personally appeared before me this day,
acknowledging to me that he voluntarily signed the foregoing document for the purpose stated
therein and in the capacity indicated:
DATE: TA , 2023
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Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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 NCG01 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 NameCollier Gate, Lots17, 18, 23, 24, 32, 33, 37, 38, 45 and 46
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g_, SRP-D ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Cumberland City or Township Carver's Creek Township
West Reeves Bridge Road 35.259744 -78.820035
Highway/Street Latitude(decimal degrees) Longitude(deeimat degrees)
3. Approximate date land-disturbing activity will commence:9/1/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.7
6. Amount of fee enclosed: $500.00 . 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 O No ❑
8. Person to contact should erosion and sediment control issues arise during [and-disturbing activity:
Name Kevin Shortridge E-mail [e-mail]
Phone: Office# 910--319-0119 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
AGS Land LLC
Name Phone: Office# Mobile#
1786 Metromedical Drive
Current Mailing Address Current Street Address
Fayetteville, NC 28304
City State Zip City State Zip
10. Deed Book No.11340 Page No.0523 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).
JSJ Builders, Inc. [e-mail]
Company Name E-mail Address
1135 Robeson Street
Current Mailing Address Current Street Address
Fayetteville, NC 28305
City State Zip City State Zip
Phone: Office#910-438-0796 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 [and 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:
JSJ Builders, Inc. [e-mail]
Name of Registered Agent E-mail Address
1135 Robeson Street
Current Mailing Address Current Street Address
Fayetteville, NC 28305
City State Zip City State Zip
Phone: Office# 91 0-438-0796 Mobile#
Kevin Shortridge
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
corr cted information should there be any change in the information provided herein.
\0 AcId8e_
Type or print namc Title or Authority
1110 7/ Kt/g
Signature Date
-------
I, /f/)i� Vic() /?OG/c- , a Notary Public of the County of ifY11�in )
State of North Carolina, hereby certify that ✓ 2'//V --s �iACr 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 /6 day of / '/1T , 20 J?
ti .`4 0i �i �
,ems�A Vj C�
0 7, , — Notary
P B My commission expires '5 �..f- -2J
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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:
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#
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#