NCC215802_FRO Submitted_20211019

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 Magnolia at Mallory Creek Plantation
2. Location of land -disturbing activity: County Brunswick City or Township Leland
Highway/Street Mallory Creek Drive Latitude 34-11-12N Longitude-78-01-10W
3. Approximate date land -disturbing activity will commence: 10/01/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 72.2 Acres
6. Amount of fee enclosed: $ 4,745.00 . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John H. Richards, P.E. E-mail Address [e-mail]/[e-mail]
Telephone [phone] Cell # 843-458-455 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
HIC Mallory Creek, LLC Attn: Victor Padilla 786-219-7174
Name
874 Walt Miller St, Suite 101
Current Mailing Address
Mt Pleasant SC 29464
City
NIA
N/A
Telephone Fax Number
777 Brickell Avenue, Suite 1270
Current Street Address
Miami FL 33131
State Zip City
Deed Book No. 4696 Page No 1312
Imo=.
State
M
Provide a copy of the most current deed.
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 fisted as the financially responsible party.
HIC Mallory Creek, LLC / Attn: Victor Padilla
Name
874 Walt Miller St Suite 101
Current Mailing Address
Mt Pleasant Sc 29464
City State Zip
[e-mail]
E-mail Address
777 Brickell Avenue, Suite 1270
Current Street Address
Miami Florida 33131
City State Zip

Telephone
786-219-7174
Fax Number
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:
Matthew G. St. Amand, Esq.
[e-mail]
Name
E-mail Address
3315 Springbank Lane, Suite 308
3315 Springbank Lane, Suite 308
Current Mailing Address
Current Street Address
Charlotte NC 28226
Charlotte NC 28226
City State Zip
City State Zip
Telephone [phone]
Fax Number 704-919-5498
(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:
E-mail Address
Name of Registered Agent
Current Street Address
Current Mailing 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.
Victor M. Padilla IV
Type mg
Signature
Authorized Signatory
Title or Authority
9�a�a
Date
I, ww VMS a Notary Public of the County of ChaV tgr' 1
Stivli►vt V�OAVY �Oldl��� 1V
State of I�appeared
Carolina, hereby certify that eared
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 �SR4rCYvtkLr , 20 2`
r
ary
Seal
My commission expires