NCC241669_FRO Submitted_20240531

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 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 Name 7129&7137 Butler Nursery Road
*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 Cumberland City or Township Grays Creek Township
Butler Nursery Road
Highway/Street SR-2233 Latitude(decimal degrees) N 34.8873° Longitude(decimal degrees) W-78.8423°
3. Approximate date land-disturbing activity will commence: April 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.15 acres
6. Amount of fee enclosed: $ 300.00 . 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 John Hyatt E-mail Address ihyatt(c�protonmail.com
Phone: Office# 910-237-7740 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Harrell Builders of NC, LLC 910-263-2945
Name Phone: Office# Mobile#
P.O. Box 451 Same
Current Mailing Address Current Street Address
Raeford NC 28376 Same
City State Zip City State Zip
7129 & 7137 7129 7137
10. Deed Book No. 11922 Page No. 460 465 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).
Kimash Homes, LLC jhyattprotonmail.com
Company Name E-mail Address
2704 Creekdew Court Same
Current Mailing Address Current Street Address
Fayetteville NC 28306 Same
City State Zip City State Zip
Phone: Office# 910-237-7740 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:
Jordan William Brock jordan.w.brock ci,outlook.com
Name of Registered Agent E-mail Address
2704 Creekdew Court Same
Current Mailing Address Current Street Address
Fayetteville NC 28306 Same
City State Zip City State Zip
Phone: Office#910-237-7740 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.
John Hyatt Manager
,-Type-or print name Title or Authority
Signature 1) Date
`1-A,.\ '(\1/4' c-Nt§Yl at\ , a Notary Public of the County of Q64Q
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him/her.
Witness my hand and `o`wigi IVl,his ` "day of P'Q(�' \ , 20
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} a0 _ Notary
My commission expires � 0�� ao
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