NCC222683_FRO Submitted_20220727

FINANCIAL RESPONSIBILITYIOWNERSHIP 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.
2.
3.
4,
5.
6.
Q
Project Name Ed ewood Farms West Lots 3 $ 11 17 and 19
Location of land -disturbing activity: County Cumberland City or Township Grays Creek Township
Highway/Street Dottie Lane Latitudetdedn,aidegrees) 34.88598 Longitude(decimaidegrees)-78.865599
Approximate date land -disturbing activity will commence: July 08, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.96 acres
Amount of fee enclosed: $ 400.00 . 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.
Has an erosion and sediment control plan been filed? Yes ✓ Enclosed ✓ No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name -Randy Jackson E-mail Address [e-mail]
Phone: Office# 910-237-1205 Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Paradise Homes of Fayetteville LLC
Name
2094 Orville St
Current Mailing Address
Eastover NC 28312
City State Zip
910-237-1205 910-237-1205
Phone: Office # Mobile #
2094 Orville St
Current Street Address
Eastover NC 28312
City State Zip
10. Deed Book No. 11171 Page No. 229 Provide a copy of the most current deed.

Part S.
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).
Paradise Homes of Fayetteville LLC
Company Name
2094 Orville St
Current Mailing Address
Eastover NC 28312
City State Zip
ncstate8794 mail.cam
E-mail Address
2094 Orville St
Current Street Address
Fayetteville NC 28312
City State Zip
Phone. Office # 910-237-1205 Mobile # [phone]
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # 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
Phc,rc: Office #
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(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 attomey-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.
Randv Jackson
Type or rint name—) I
s
Signature
Owner/Manager
Title or Authority
Cf 0�
Date
I, L4yel a Notary Public of the County of Cc.c tsar
State of North Carolina, hereby certify that E 4N❑ f C�CSc ]_ _ appeared
personally before me this day and being duly swom acknowledged that the above form was
executed by him/her.
r� r
Witness my hand and notarial seal, this 27 day of u NA- , 20 e2 --Z
Notary Public
�'�"�' Si✓trpr,vR Epler Nota
Cumberlag� Count
�i®rtb Carolina My commission expires `7
N--

Continued from Items 9 & 70 in Part A of the Financial Responsibility/Ownership Form
for multiple owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Paradise Homes of_ Fayetteville, LLC 910-237-1205 910-237-1205
Name Phone: Office # Mobile #
2094 Orville St 2094 Orville St
Current Mailing Address Current Street Address
Eastover NC 28312 Eastover NC 28312
City State Zip City State Zip
Deed Book No. 11345 Page No. 592 Provide a copy of the most current deed.
Landowner 3 of Record.
Paradise Homes of Fayetteville, LLC 910-237-1205 910-237-1205
Name Phone: Office # Mobile #
2094 Orville St 2094 Orville St
Current Mailing Address Current Street Address
Eastover NC 28312 Eastover NC 28312
City State Zip City State Zip
Deed Book No. 10377 Page No. 17 Provide a copy of ti its most current deed
Landowner 4 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 5 of Record:
Name
Current Mailing Address
State Zip
Page No.
City State Zip
Deed Book No. Page No.
Phone: Office # Mobile #
Current Street Address
C ity State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
City State Zip
Provide a copy of the most current deed.