NCC220361_FRO Submitted_20220119

N&T #21040
FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank).
Park A.
1. Project Name Calabash 15
2. Location of land -disturbing activity: County
Brunswck
Highway/Street NC179 Beach Dr. Latitude 33.1893
City or Township Calabash
Longitude -78.° 572
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12.9
6. Amount of fee enclosed. $ 845.00 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name J. Phillip Norris, P.E. _ E-mail Address [e-mail]
Telephone [phone] Cell # 910471-9638 Fax # [phone]
91
Landowner(s) of Record (attach accompanied page to list additional owners):
Cranwood Carolina Capital, LLC 330-867-2400
Name Telephone
381 Tanglewood Lane
Current Mailing Address Current Street Address
Bay Village._ OH 44140
City State Zip City
Fax Number
State
M
10. Deed Book No. 4709 Page No. 7 032 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):
Cranwood Carolina Capital, LLC
Name
381 Tanglewood Lane
Current Mailing Address
Bay Village OH 44140
City State Zip
[e-mail]
E-mail Address
Current Street Address
City
Telephone [phone] Fax Number
State Zip

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:
drvrsvJ �c.�C Ser,,oc 0Wex, @C.caz�,.avooa O_ ; �� • c.yn,
Name F-mail Address
3( d,o LYress :,J�_
Current Mailing Address
s\yip Ne. a�y70_ `svl
City State Zip
Telephone qlt1- 1 Sri- A 30y
Current Street Address
City
Fax Number
Zip
(b) [f 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
State
Telephone
Zip City
Fax Number
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 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.
Tom Charek Manager
Type or prame Title or Authority
`- /3
Signature
Date
a Notary Public of the County of uw.rw��r
b4..,o
State of Nerth Carolina; hereby certify that
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 DCr 20 _
Seal Notary
My commission expires
Chelsea Jenkins
Notary Public. State of Ohio
My Commission Expires:
06/29/2026