NCC215294_FRO Submitted_20210924

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 Moss East
2. Location of land -disturbing activity: Beaufort County or Township Washington
Highway/Street East Water Street Latitude 35.5382' Longitude 77.0489°
3. Approximate date land -disturbing activity will commence: June 15, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.59
6. Amount of fee enclosed: $ 455 . 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name James K. Wiley E-mail [e-mail]
Telephone [phone] Cell # 919-795-3380 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Beacon Street Moss East, LLC _ 919-785-1445 919-785-1446
Name Telephone Fax Number
P. O Box 6474 3304 Six Forks Road, Suite 104
Current Mailing Address Current Street Address
Raleigh NC 27628 Raleigh NC 27609
City State Zip City State Zip
10. Deed Book No. 1829 Page No. 481 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):
Beacon Street Moss East LLC James K. Wiley, Manager iwileyCcDbeacon-street.com
Name E-mail Address
P. O. Box 6474 3304 Six Forks Road, Suite 104
Current Mailing Address Current Street Address
Raleigh NC 27628 Raleigh NC 27608
City State Zip City State Zip
Telephone [phone] Fax Number 919-785-1446
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
James K. Wiley Manager
Type or print name; Title or Authority
Signature ~' Date
T-1 1-0 a Notary Public of the County of 1�
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State of North Carolina, hereby certify that C' .-4 --I( !> 'd" + rt'.� appeared
personally before me this day and being duly sworn acknowledged -that the above form was
executed by him.
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Witness my hand and notarial seal, this i D day of l- Pi"O 20
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