NCC243046_FRO Submitted_20241007

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 Environment and Natural Resources. (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.
1. Project Name, The Bluffs on the Cape Fear Phase 5
2. Location of land-disturbing activity: County Brunswick City or Township Northwest
Highway/Street Located off Dogwood (SR 1428) in north Brunswick County.
Latitude 34°20'5" Longitude 78°03'97"
3. Approximate date land-disturbing activity will commence: Upon Permit Receipt
4. Purpose of development(residential, commercial, industrial, institutional, etc.) Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10.45 acres total; 7.99 acres
previously permitted. 2.46 acres additional in this request.
6. Amount of fee enclosed: $195 ($520 Paid) The application fee of $65.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount(Example: a 9-acre application fee is$585).
7. Has an erosion and sediment control plan been filed? Yes ❑ No ❑ Enclosed El
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Gary Lattie E-mail Address glattieAnc rr.com
Telephone [phone] Cell# Fax#
9 Landowner(s) of Record (attach accompanied page to list additional owners):
Bluffs Investment LLC [phone]
Name Telephone Fax Number
P.O. Box 4937 145 Brookline Drive
Current Mailing Address Current Street Address
Pinehurst NC 28374-4937 Pinehurst NC 28374-7129
City State Zip City State Zip
10. Deed Book No.04041 Page No.0828 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a comprehensive list of all
responsible parties on an attached sheet):
Bluffs Investment LLC 1910)639-3218
Name Telephone Fax Number
P.O. Box 4937 145 Brookline Drive
Current Mailing Address Current Street Address
Pinehurst NC 28374-4937 Pinehurst NC 28374-7129

Telephone Cell# Fax#
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:
N/A
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Cell# Fax#
(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:
Douglass S. Talbot, Registered Agent [phone]
Name Telephone Fax Number
P.O Box 4937 145 Brookline Drive
Current Mailing Address Current Street Address
Pinehurst NC 28374-4937 Pinehurst NC 28374-7129
City State Zip City State Zip
Telephone Cell# Fax#
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 Person). I agree to provide corrected information should there by
any change in the information provided herein.
Dou.i. •ot Registered Agent
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i, .Av)Cie_ b. 5 )•k.__ , a Notary Public of the County of Nt'- - H d 11 ‘ V-C . State of
North Carolina, hereby certify that 1)0t_tcc}}( _5 -7 c,;iho-i 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 . day of / 0 Po !i,v , 20 '- .
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