NCC222626_FRO Submitted_20220725

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Residences at Bask
2. Location of land -disturbing activity: County
Highway/Street LatltUde(decimaldegrees) Long Carteret City or Township Morehead City
901 & 909 Shepard St 34.7195-76.7150
_
3. Approximate date land -disturbing activity will commence: June 15, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_ Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.65 acres
6. Amount of fee enclosed: $_ 300.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name William A. Brown, Manager E-mail Address [e-mail]
Phone: Office # 252-726-1005 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Residence at 9th, LLC 252-726-1005
Name
125 Horton Drive
Phone: Office # Mobile #
Current Mailing Address Current Street Address
Morehead City NC 28557
City State Zip City State Zip
10. Deed Book No. 1763 & 1765 Page No. 241 & 374 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Residence at 9th, LLC [e-mail]
Company Name
125 Horton Drive
Current Mailing Address
Morehead City NC 28557
City State Zip
Phone: Office # 252-726-1005
E-mail Address
Current Street Address
City State
Mobile # [phone]
Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Beth F. Atkins
Name of Registered Agent
PO Box 975
Current Mailing Address
New Bern NC 28563-0975
City
State Zip
Phone: Office # [phone]
[e-mail]
E-mail Address
2918 Trent Road
Current Street Address
New Bern NC 28562-2030
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
William A. Brown Manager, Residence at 9th, LLC
Type or print name
CG r
Signature
Title or Authority
�4 . 2.2.
Date
I, Lwym Q. %q& C.OX , a Notary Public of the County of C.QY�eXti
State of North Carolina, hereby certify that W MmyY1 N • 1by0w Yl appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of kki nt, 20 2ZE
yc , Notary
O�
'VAR y
Seal
PUBOO My commission expires 2� 202
x'
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Current Mailing Address
City
Deed Book No
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address
Current Street Address
City State Zip City
Phone: Office # _ Mobile #
Zip
State Zip