NCC221933_FRO Submitted_20220523

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 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 the blank.)
Part A. West Pointe at Autumnwood Phase I
1 Project Name
2 Location of land -disturbing activity: County Lee City or TownshipSanford
Highway/StreetValley Road Latitude35030'18" Longitude7901313811
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 7.7+1 .3=1 9
6. Amount of fee enclosed: $ 1,170.00+100= 1,270.00. 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 X No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameCorey Schmidt E-mail Addresscschmldt@e1 homes.com
Telephone [phone] cell # 919-418-8994 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
ExperienceOne Homes, LLC 919.991.1428 919.991.1402
Name
P.O. Box 5509
Current Mailing Address
Cary, NC 27512
City State Zip
10. Deed Book No.2021 Page
Telephone Fax Number
2818 Core Banks St.
Current Street Address
Apex, NC 27523
City State Zip
210 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.) It the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
ExperienceOne Homes, LLC dschmidt@e1 homes.com
Name E-mail Address
P.O. Box 5509
Current Mailing Address
Cary, NC 27512
City State
Telephone[phone]
2818 Core Banks St.
Current Street Address
Apex, NC 27523
City State Zip
Fax Number919-991-1402

(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
N/A
Name
N/A
Current Mailing Address
N/A
City State Zip
Telephone N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Fax Number N/A
(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:
Corey Schmidt cschmidt@e1 homes.com
Name of Registered Agent
P.O. Sox 5509
Current Mailing Address
Cary, NC 27512
City State Zip
Telephone[phone]
E-mail Address
2818 Core Banks St.
Current Street Address
Apex, NC 27523
City State Zip
Fax Number919-991-1 '402
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
c cted 'nfor tion should ere a any c ange in the in rmation provided herein.
?C" 91 j4 A)AvrXk
T p Title o A tr rity
Signature Date
I, �J_LYV-1 C�V1 , a Notary Public of the County of 1+aA44P -t
State of North Carolina, hereby certify that 1:bA1.1 l'W4W SCr_I .VVUJ-E appeared
personally before me this day and being duly sworn ack owledged that the above form was
executed by him.
`Iplil111//ll� r'
Witness mY�, `n. d Lea%,�seal, this day of 20 _
�4 � •wwwwa, ��j,
1 , e Notary
Seal
(, My commission expires,$
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