NCC220824_FRO Submitted_20220322

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 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.
1. Project Name. Currin Hill Subdivision Phase I - Lots 9 37. 48 & 49
2. Location of land -disturbing activity: County Cumberland City or Township Carvers Creek Township
Highway/Street
Nairn Street
Latitude N 35.1985' Longitude W-78.8697°
3. Approximate date land -disturbing activity will commence: January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.93 Acre
6. 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).
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 Adam Furr
Telephone [phone] Cell #
E-mail Address adamfurr10Ca7gmail.com
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Box 2824
Current Mailing Address
Fayetteville NC 28302
City State Zip
910-391-3670
Telephone Fax Number
327 Dick Street, Ste 102
Current Street Address
Fayetteville NC 28301
City State Zip
10. Deed References: DB 11353 PG 851 Copies provided.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide
comprehensive list of all responsible parties on an attached sheet):
Furr Construction and Development, Inc_
Name
P.O Box 2824
Current Mailing Address
Fayetteville NC 28302
City State Zip
Telephone [phone]
urrproperties anamai1 com
E-mail Address
327 Dick Street, Ste 102
Current Street Address
Fayetteville NC 28_301
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
Current Mailing Address
E-mail 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
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.
Harold G. Furr Jr. Reg. Agent
ype or print name Title or Authority
ignature Date
" 1�z I ] I, r 30 sr"+Vq , a Notary Public of the County of Cqna�ydond
State of North Carolina, hereby certify that llau 16 P E'ri Jr 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 J U) , 20 lid
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