NCC243014_FRO Submitted_20241018

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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name Forest Run
2. Location of land-disturbing activity: County Brunswick City or Township Shallotte
Highway/Street Village Point Road Latitude 33.9345 Longitude -78.3804
3. Approximate date land-disturbing activity will commence: Upon issuance of permit
4. Purpose of development(residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 19.9
6. Amount of fee enclosed: $ 2000 . 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).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed x
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name David L. Menius, P.E. E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
1295 Village Point Road, LLC 910-515-1830
Name Telephone Fax Number
711 Carolina Beach Avenue North 711 Carolina Beach Avenue North
Current Mailing Address Current Street Address
Carolina Beach NC 28428 Carolina Beach NC 28428
City State Zip City State Zip
10. Deed Book No. 5068 Page No. 88 Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
1295 Village Point Road, LLC [e-mail]
Name E-mail Address
711 Carolina Beach Avenue North 711 Carolina Beach Avenue North
Current Mailing Address Current Street Address
Carolina Beach NC 28428 Carolina Beach NC 28428
City State Zip City State Zip
Telephone [phone] 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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Brian Fleer [e-mail]
Name of Registered Agent E-mail Address
711 Carolina Beach Avenue North 711 Carolina Beach Avenue North
Current Mailing Address Current Street Address
Carolina Beach NC 28428 Carolina Beach NC 28428
City State Zip City State Zip
Telephone [phone] Fax Number
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 be any change in the information provided herein.
Brian Fleer, Member, 1295 Village Point Road, LLC �� •�''\a,i.tic, ^ NVQ,....ii tCs.
Type or print t name Title or Authority
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Signature Date
a Notary Public of the County of
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State of North Carolina, hereby certify that r.r- , � •., f I o r 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 , 20
KRIS i.:::c.FOOOY
, NotaryPublic•North Carolina� - t
NEW OVER COUNTY Notary
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