NCC220976_FRO Submitted_20220309

NC Dept of Environmental oipalil %
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM JAN 2 5 L22
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by thAwwikaeo dual 4 f(•i,
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.
Project Name The Provisions at Courtland
2. Location of land -disturbing activity: County Lee City or Township Sanford
Highway/Street_ Courtland Drive_ Latitude_35.45448 d_ Longitude_-79.16989 d
3. Approximate date land -disturbing activity will commence: Jan. 3. 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovers (including off -site borrow and waste areas): 14.5
6177S 1 5—o2.5'
6. Amount of fee enclosed: $ $1.500 . The application fee of $100.00 per acre (rounded up to
the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
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 Christian Provision Ministries E-mail Address [e-mail]
Telephone [phone] Cell # _919-770-1494 Fax # n/a,
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Christian Provision Ministries, Inc. 919-770-1494 n/a
Name Telephone Fax Number
2300 W. Courtland Drive 2300 W. Courtland Drive
Current Mailing Address Current Street Address
Sanford NC 27330 _ Sanford NC 27330
City State Zip City State Zip
10. Deed Book No. 695 Page No. 243 Provide a copy of the most current deed.
Part B.
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.
_ Christian Provision Ministries, Inc.
Name
_ 2300 W. Courtland Drive
Current Mailing Address
_ bishop(a)christianprovision.com _
E-mail Address
2300 W. Courtland Drive
Current Street Address
_ Sanford NC 27330 _ Sanford NC 27330
City State Zip City State Zip
Telephone [phone] Fax Number n/a

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:
nla
Name
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
(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:
nla
Name of Registered Agent
Current Mailing Address
E-mail 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.
Type R pr t name Title or Authority
c' 1) "'_ /-- _ Z
Sign ure Date
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I, CL c e-} I R, I :L r, , a Notary Public of the County of Ze
State of North Carolina, hereby certify that Y0 r-l.r--5 �e Z"- appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
� tl,
Witness my hand and notarial seal, this 12 day of A n Onr , 20 �
0. 40t�-.
CAROL D FULTON Notary
EMy
ry Plfms North Carolina
Lee County
Commission Expires My commission expires )A
October 08, 2023