NCC220749_FRO Submitted_20220214

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. Westport Lofts
1. Project Name
FIA
3
Location of land -disturbing activity: County Brunswick City or Township Belville
Highway/Street NC Hwy 133 Latitude 34°13'37" N Longitude 77059'12" W
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): 20 acres
6. Amount of fee enclosed: $ 1,300 . 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 Bentley Nelson E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Monica C. Watson
Name
2651 Blue Banks Loop Road NE
Current Mailing Address
Leland NC 28451
Telephone Fax Number
2651 Blue Banks Loop Road NE
Current Street Address
Leland NC 28451
City State Zip City
10. Deed Book No. 829 Page No. 937
State
�"
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.
Crest Residential, LLC [e-mail]
Name
500 Office Park Drive, Suite 215
Current Mailing Address
Birmingham AL 35223
City State
Telephone 205 - 566 - 2384
E-mail Address
500 Office Park Drive, Suite 215
Current Street Address
Birmingham AL 35223
Zip City
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:
Paracorp Incorporated
Name
E-mail Address
176 Mine Lake Court #100
176 Mine Lake Court #100
Current Mailing Address
Current Street Address
Raleigh NC 27615
Raleigh NC 27615
City State Zip
City State Zip
Telephone [phone]
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.
Matthew Benak
Type or print name
Y��L �- g-k
Signature
Manager
Title or Authority
Date
C. a Notary Public of the County of Je_ VC30A
(�i- l C`�crnna
State of , 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 ark day of 20 �d\
Seal
HOUSTON CASWELL SMITH
AMA STATE AT LARGE
MY OMM SS ON NOTARy PUBLIC, EXPIRES FEB. 2024
. \�Qj&n
Notary
My commission expires F!!B� t4.�0�`4