NCC220821_FRO Submitted_20220304

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. Laurel Ridge - Lot 37
1. Project Name
2. Location of land -disturbing activity: Count Chatham City or Township Pittsboro
Highway/Street51 Bluffside Ct Latitude35.8064 Longitude-79.2106
3. Approximate date land -disturbing activity will commence:02/28/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):0.67 acres
6. Amount of fee enclosed: $ 100.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameBlake Terry E-mail [e-mail]
Telephone [phone] cell # 956-250-5408 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cotton Custom Homes
919-367-8165
Name
Telephone Fax Number
1617 Center Street
Current Mailing Address
Current Street Address
Apex, NC 27502
City State
Zip City State Zip
10. Deed Book No. 2188
Page No.0782 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.
Cotton Custom Homes, Inc
[e-mail]
Name
E-mail Address
1617 Center Street
same
Current Mailing Address
Current Street Address
Apex, NC 27502
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:
William Cotton [e-mail]
Name
1617 Center Street
Current Mailing Address
Apex, NC 27502
City State
Telephone [phone]
E-mail Address
Current Street Address
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 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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
William otton President
Type o r' ame Title or Authority
." February 15, 2022
Signs re Date
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Gina M. Jiampetti , a Notary Public of the County of Wake
State of North Carolina, hereby certify that William P. Cotton 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 15
GINA M JIAMPETTI
SeaNOTARY PUBLIC
WAKE COUNTY, NC
UY commission Expires
day of February 2022
Not
My commission expires September 6, 2026