NCC222977_FRO Submitted_20220906

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. Compass Pointe Phase 1 Section 5A
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Leland
Highway/Street Palm Pointe Road Latitude 34015'54"N Longitude 78°04'48"W
3. Approximate date land -disturbing activity will commence: September 30, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.67 AC
6. Amount of fee enclosed: $ 700 . 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 Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Greta Harrelson E-mail Address [e-mail]
Telephone [phone] Cell # N/A Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CP Brunswick, LLC [phone] [phone]
Name Telephone Fax Number
113 N Third Street, Suite 30 113 N Third Street, Suite 300
Current Mailing Address Current Street Address
Wilmington NC 28401 Wilmington NC 28401
City State Zip City State Zip
10. Deed Book No. 3225 Page No. 0830 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.
CP Brunswick, LLC N/A
Name
113 N Third Street, Suite 300
Current Mailing Address
Wilmington NC 28401
City State
Telephone [phone]
Zip
E-mail Address
113 N Third Street, Suite 300
Current Street Address
Wilmington NC 28401
City State Zip
Fax Number [phone]

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
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Bobby Harrelson
Name of Registered Agent
113 N Third Street, Suite 300
Current Mailing Address
Wilmington NC 28401
City
State Zip
Telephone [phone]
N/A
E-mail Address
113 N Third Street, Suite 300
Current Street Address
Wilmington NC 28401
City State Zip
Fax Number [phone]
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.
Greta Harrelson President
Type or print nam�e Title or Authority
Signature Date
l _
I, a Notary Public of the County of
State of North Carolina, hereby certify that Greta Harrelson
personally before me this day and being duly sworn acknowledged that
executed by him.
appeared
the above form was
Witness my hand antact_nt�erial seal, thday of /� , 20,
'Y
NOTARY
Notary
Sea PUBLIC
My commission expires
V R G�