NCC215737_FRO Submitted_20211019

FINANCIAL RESPONSISILITYIOWNERSHIP FORM -
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as coveiii8liy.1,V�A6t'-b6e 6 e•t4li)r17'.ClI
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 NIA in the blank.)
Part A. Lots 7, 8, & 13 Gretchen Pines Subdivision Phase 1
1. Project Name
2. Location of land -disturbing activity. County Moore City or Township Minefai Springs
Highway/Street NC Hwy 73 Latitude 35.2488 Longitude 79.5479
3. Approximate date land -disturbing activity will commence. April 2021
4. Purpose of development (residential, commercial industrial, institutional. etc.); Residential
5. Total acreage disturbed or uncovered (including off -site borrow amJi waste aweas). 1 •3 AC
B. Amount of fee enclosed: $ 130 . The application fee of $65.00 per acre (rounded
LP 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 Archie Simmons - Dlscover Homes LLC E-mail Address dtscovel•i• [e-mail]
Telephone cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Archie Simmons - Discover Homes LLC [phone]
Name Telephone Fax Number
PO Box 695
Current Mailing Address Current Street Address
West End NC 27376
City State Zip City State Zip
10. Deed Book No, 5548 Page No. 170 Provide a copy of the most current deed.
Part S.
1. Company(ies) or firill 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 scle proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Archie Simmons - Discover Homes LLC [e-mail]
Name E-mail Address
PO Box 695
Current Mailing Address Current Street Address
West End NC 27376
City State Zip City State Zip
Telephone[phone] 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:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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 Certlflcate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent. -
Archie Simmons - Discover Homes LLC
Name of Registered Agent
PO Box 695
Current Mailing Address
West End NC 27376
City
discoverhomes[[e-mail]
E-mail Address
Current Street Address
State Zip City
Telephone [phone]
Fax Number
State Zip
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 attomey-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.
Arch' Simmons Member-LLC
Tyr or r in me 4 Title or Aut ority
l�
Signature Date
I, L161-4 U e�V..s eeyyktr,,A , a Notary Public of the County of AA. )Ord
State of North Carolina, hereby certify that P `ac S`eexw�-QnI appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by hire.
Witness my hand and notarial seal, thisa'"day of��cti� 202 I
LEYDY DUENAS RG,NTERiA
Notary Public, North Carolina Nota
Moore County
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