NCC220829_FRO Submitted_20220322

FINANCIAL RESPONSIBILITYIOWNERS HIP 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.)
Part A.
3.
4,
5.
6.
7.
8.
Project Name: Rufus Johnson Road Subdivision — Lots 5-8
Location of land -disturbing activity: County Cumberland City or Township Grays Creek Township
Highway/Street Rufus Johnson Road SR-2258 Latitude N 34.8385' Longitude W-78.8936°
Approximate date land -disturbing activity will commence: January 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.92 Acre
Amount of fee enclosed: $ 200.00 . The application fee of $100.00 per acre (rounded up to the
next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Adam Furr
Telephone [phone] Cell #
E-mail Address [e-mail]
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Furr Construction and Development, Inc.
Name
P.O Box 2824
Current Mailing Address
Fayetteville NC 28302
City State Zip
910-391-3670
Telephone
327 Dick Street Ste 102
Current Street Address
Fax Number
Fayetteville NC 28301
City State Zip
10. Deed References: DB 11341 PG 557 Copies provided.
Part B.
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).
Furr Construction and Development Inc
Name
P.O Box 2824
Current Mailing Address
Fa etteville NC 28302
City State Zip
Telephone [phone]
Furmronerties wnail.com
E-mail Address
327 Dick Street Ste 102
Current Street Address
Fayetteville NC 28301
City State Zip
Fax Number

(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 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.
Harold G. Furr Jr.
Type or print name
tore
Rea. Anent
Title or Authority
Gf
Date
a Notary Public of the County of Wes✓
State of North Carolina, hereby certify that Ha K'?k �� ��'"� 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 20 22-
KRISTINA L. HIEUSCHER
Notary Public
VMptt Co., North Carolina
My Commission Expires Dec. 22, 2024
of ry
My commission expires - 2 2 - -)-D2