NCC221937_FRO Submitted_20220531

NT# 21054
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 NIA in the blank.)
Part A. The Hamptons Multi -Family
1. Project Name
2. Location of land -disturbing activity: Countyl3runswick City or Township Calabash
Highway/Street Number 5 School Rd. Latitude 33.952 Longitude 78.567"
3. Approximate date land -disturbing activity will commence: April 1 , 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 27.56
6. Amount of fee enclosed: $ 1,100.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name J. Phillip Norris, P.E. E-mail Address [e-mail]
Telephone [phone] cell # 910-471-9638 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Caw Caw Land Corporation
910-443--4800 NIA
Name
Telephone Fax Number
252 S. Middleton Dr. NW
252 S. Middleton Dr. NW
Current Mailing Address
Current Street Address
Calabash NC 28467
Calabash NC 28467
City State Zip
City State Zip
10. Deed Book No. 2120 Page No.
1228 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.
Caw Caw Land Corporation
[e-mail]
Name
E-mail Address
252 S. Middleton Dr. NW
252 S. Middleton Dr. NW
Current Mailing Address
Current Street Address
Calabash NC 28467
Calabash NC 28467
City State Zip
City State Zip
Telephone [phone]
Fax Number NIA

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.
George Sloane, III Vice President/ Secretary
Tvpe,dr print naufe ) _1__7 Title or Authority
i6n,af&O Date ..•
IcisqM&JOL6n a Notary Public of the County of V :)`'A p5w .(
State of North Carolina, hereby certify that 'JAoau appeared
personally before me this day and being duly swot acknowledged that the above form was
executed by him. Af
lWitness my hand and notarial seal, this day of Y� 20_
TAMMY T WATSON
SePrunswickOTARY PUBLIC
County
North Carolina
My Commission Expires May 20, 2023
ary
My commission expires_ S- " - d