NCC221106_FRO Submitted_20220318

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 pla; have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed fo=m to J e
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.)
Pa t A. Gates Four block Q
1. Project Name
2. Location of land -disturbing activity: County Cumberland ;;ity or Township`�-OCkfiSh
Highway/Street SCothol rl^ D r?ve Latitude 35.002269 Longitude 79.020419
3. Approximate date land -disturbing activity will commence: March 2021
4. Purpose of development (residential, commercial, .ndustrial. institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 26.78
6. Amount of fee enclosed: $ 1755.00 . 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 No Enclosed XX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name George Armstrong E-mail Address erind@c-Sprop
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pelican Property Holdings, LLC 910-864-3232
Name Telep.�one Fax Number
2709 T1'9ornarove Court 2709 Thorngrove Court
Current Mailing Address Current Street Address
Fayetteville NC 28303 Fayetteville NC 28303
City State Zip City State Zip
10. Deed Book No. 8869 Page No. 003 Provide a copy of the most current deed.
=marl 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.
Pelic2r Property Holdings, LLC rj>[e-mail]
Name E-mail Address
2709 Thorngrove Court 2709 Thorngrove Court
Current Mailing Address Current Street Address
Fayetteville NC 28303 Fayetteville NC 28303
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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Telephone
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.
Robert J. Williams, V
President -Pelican Property Holdings, LLC
Type print name Title or Authority
Signature Date
a Notary Public of the County of 14p KE
State of North Carolina, hereby certify that -Knaxr�- z-. �.�]� �� i'a�,-,S' �` appeared
personally before me this day and being duly sworn acknowledged tha the above form was
executed by him.
Witness my hand and notarial seal, this day of w r. � 20'-) 0
0 UG4''%,,•,
' OTA[ y)_ Notary
Seal
�'UB0G ,�0 ' My commission expires_ �'

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL AC --
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 -he blank.)
Part A. Gates Four Block Q
1. Project Name
2. Location of land -disturbing activity: County Cumberland City or Township Rockfish
Highway/Street Scothol m Dr. Latitude 35. 002269 Longitude 79.020419
3. Approximate date land -disturbing activity will commence: March 2021
4. Purpose of development (residential, csi -.i —ercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 26.78
6. Amount of fee enclosed: $ ' 755 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Ex'ar-ple: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed XX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name George Armstrong E-mail Address erind a)c-sprop.com
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CJR € roperty -inl6Ji gs, LLC
910-864-3232
Name
Telephone Fax Number
27E09 __- ,orngrove Court
2709 Thorngrove Court
Current Mailing Address
Current Street Address
Fayetteville NC 28303
Fayetteville NC zB303
City State Zip
City State Zip
10. Deed Book No. 8869 Page No. 003 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.
CJR ;property Holdings, i_LC
[e-mail]
Name
E-mail Address
2709 Thorngrove Court
2709 Thorngrove Court
Current Mailing Address
Current Street Address
Fayetteville NC 28303
Fayetteville NC 28303
City State Zip
City State Zip
910-864-3232
Telephone
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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Telephone
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.
Type or printfname
CA&&Z"� /� -
Signature
President-UR Property Holdings, LLC
Title or Authority
�2--aQaD
Date
I, �� J �A„jt� : a Notary Public of the County of V30 k,Q
State of North Carolina, hereby certify that _CL-' olit] 'A O'rr5`�t"" appeared
personally before me this day and being duly sworn acknowledged th t the above form was
executed by 41m.
Witness my ha, rjd.ana1,gptarial seal, this , day of L ece�nLwr 20CL0
0 UGz
Notarf
'S =
SeOUB0
O • - �V My commission expires i' i • _

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 Envi:-:nmental 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.)
� A1 r' Project Name Gates Four Block Q
2. Location of land -disturbing activity: County Cumberland ;Jty or Township Rockfish
Highway/Street SCotholm Dr. Latitude 35.002269 Longitude 79.020419
3. Approximate date land -disturbing activity will commence: March 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 26.78
6. Amount of fee enclosed: $ 1755.00 . 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__ Nc. Enclosed XX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name George Armstrong E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
K&Js Properties, LLC 910-a,64-3135
Name Telephone Fax Number
4200 Morganton Rd., Ste 150 4-200 Morganton Rd., Ste 150
Current Mailir-g Address Current Street Address
Fayetteville NC 28314 Fayetteville NC 28314
City State Zip City State Zip
10. Deed Book No. 8869 Page No. 003 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.
K&Js Properties, LLC riddlecol^[e-mail]
Name
4200 Morganton Rd., Ste 150
Current Mailing Address
Fayetteville NC 28314
City State Zip
Telephone [phone]
E-mail Address
4200 Morganton Rd., Ste 150
Current Street Address
Fayetteville NC 28314
City State Zip
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Joseph P. Riddle, III
Type or print name
President-K&Js Properties, LLC
Title or Authority
r ► Imo- (1-z- 0 2 0
nat re Date
I, C \rslti 2 A - bwaQS -,a Notary Public of the County of l.uo'lzkPlo"d
State of North Carolina, hereby certify that Jd P. idol le 11)` 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,
01111111111,
NOTARY N c
=jea I �
PUBLICIF
this day of , 20 -
LA
Notary
My commission expires 04 t ty I