NCC221512_FRO Submitted_20220421

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 Charleston Commons at Jackeys Creek # Bruns-2007-312
2. Location of land -disturbing activity: County Brunswick City or Township Leland
Highway/Street NC HWY 133 Latitude 34012'12.6311N Longitude 7T5852.23"W
3. Approximate date land -disturbing activity will commence: Apol 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.)., -Town hme cornl2lex
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10.86
6. Amount of fee enclosed: $ _ 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name James Luke E-mail Address duke Mornco5.com
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
JC LEL4ND COMPANY LLC 267-356-4111
Name Telephone Fax Number
1037 BULLARD CT STE 208
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip
10. Deed Book No. 3121 Page No. 1268 Provide a copy of the most current deed,
Part B.
1. 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):
JC LELAND COMPANY LLC [e-mail]
Name E-mail Address
1037 BULLARD CT STE 208
Current Mailing Address Current Street Address
RALEIGH NC 27609
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
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:
r+
Name of Registered Agent
Current Mailing Addres
WI.�61 1� 296S
City State Zip
Telephone ) . -qW
,XLLik� 0, fWW40 s. kiwi
E-mail Address
C 3S- 35�_
Current Street Address
City State Zip
Fax er
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.
.u-Gk._
Type or print name
Si na e
Title or Authority
2 2 22-
Date
a Notary Public of the County of-&1W If
State of North Carolina, hereby certify that 1- 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 _2$ _day of I Ct , 20 Z '1__
LEXY SCOTT
NOTARY PUBLIC
New Hanover County
North Carolina Notary
My Co on Expires 11/08/2026
My commission expires 6!An 7, L 2- r12