NCC243151_FRO Submitted_20241011

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 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 Percival Square Apartments
2. Location of land-disturbing activity: County Hoke City or Township Raeford
Highway/Street W• Palmer Street Lat1tudeto.i,aaJ deg..)34.9736 Longitudeca.dmai d.gr..ai-79.2427
3. Approximate date land-disturbing activity will commence:October 2024
4. Purpose of development(residential,commercial, industrial, institutional,etc.):Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):5
6. Amount of fee enclosed: $500 . 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 0 Enclosed p No El
8. Person to contact should erosion and sediment control issues arise during Land-disturbing activity:
Name T. Kevin Connelly E-mail Address [e-mail]
Phone: Office# 803-798-0572 Mobile# [phone]
9 Landowner(s)of Record(attach accompanied page to list additional owners):
JOSEPH P. RIDDLE ill 2020 ESCROW TRUST 910-864-3135 910-864-3135
Name Phone: Office# Mobile#
P.O. Box 53729 4200 Morganton Rd, Suite 150
Current Mailing Address Current Street Address
Fayetteville NC 28305 Fayetteville, NC 28314
City State Zip City State Zip
Page No.0740
10. Deed Book No. 1352 Provide a copy of the most current deed.

Part B.
. Company(iesl 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 lendowner(s)u
an individual(s) the name(s)of the owner(s)may be listed as the financially responsible parfy(ies).
Connelly Builders, Inc. [e-mail]
Company Name E-mail Address
125 Old Chapin Road
Current Mailing Address Current Street Address
Lexington SC 29072
City State Zip City State Zip
Phone: Office# 803-798-0572 Mobile# '8d3 -5 l3 -1 o Sc
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:
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)
(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:
Blanco Tackabery & Matamoros, PA tlma arr,c..c,`Qc.).), uL,rr
Name of Registered Agent E-mail Address
P.O. Drawer 25008 404 N. Marshall Steet
Current Mailing Address Current Street Address
Winston-Salem NC 27114 Winston-Salem NC 27101
City State Zip City State Zip
Phone:
Office# [phone] Mobile#
boR
Name of Individual to Contact(if Registered A ent is a company)

(c)If the Financially Respons ble Party is engaging in business under an assumed name,give name under
which the company is Doing Business As If the Financially Responsible Party s 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.
T. Kevin Connelly President
Type or print name Title or Authority
Signature Date
a1�r-,, a Notary Public of the County of hQ-i14rq im
State of Nerlh Carolina,hereby certify that 7 Y.21.)kr>. Cc ..iei appeared personally
before me this day and being duly sworn acknowledged that the above form 4as executed by him/her.
Witness my hand and notarial seal, this 2-14k day of no r , 20 a3
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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:
TRINA T. RIDDLE 2020 ESCROW TRUST 910-8964-3135 910-864-3135
Name Phone: Office# Mobile#
P.O. Box 53729 4200 Morganton Rd, Suite 150
Current Mailing Address Current Street Address
Fayetteville NC 28305 Fayetteville, NC 28314
City State Zip City State Zip
Deed Book No. 1352 Page No 0740 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.