NCC223406_FRO Submitted_20221003

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 Environment and Natural Resources. (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.
1. Project Name: Glendale Arbor
2. Location of land -disturbing activity: County: Brunswick City or Township: _
Highway/Street US Hwy 17 Latitude: 33° 56' 42.33" N Longitude: 78' 28' 39.85"W
3. Approximate date land -disturbing activity will commence: September 1 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 85.78 ac..
6. Amount of fee enclosed: $ 5,590 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 No: Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name D Logan E-mail Address: Dlogan(u7loganhomes.com
Telephone: [phone] Fax #: [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
OIB138 Ventures LLC [phone]
Name Telephone Fax Number
60 Gregory Rd, Suite 1 Same as Mailing Address
Current Mailing Address Current Street Address
Leland NC 28451
City State Zip City
10. Deed Book No. 4652 Page No. 917
Part B.
State
Provide a copy of the most current deed.
Zip
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
0IB138 Ventures LLC [phone]
Name Telephone Fax Number
60 Gregory Rd Suite 1 Same as Mailing Address
Current Mailing Address Current Street Address
Leland NC 28451
City State Zip City State Zip

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 State Zip
Telephone
E-mail Address
Current Street Address
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:
Name of Manager
Current Mailing Address
City State Zip
Telephone:
E-mail Address
Current Street Address
City State Zip
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.
D Logan Manager
Type or print name Title or Authority
Signature Date
-------------------
, a Notary Public of the County ofkylwhdA
State of North Carolina, hereby certify that (3 :L.l. Q. 6t VI appeared
personally before me this day and being duly sworn ackn wledged that the above form was
executed by him. ��
Witness my hand and notarial seal, this ti"
��= day of S , 20 Z
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Kris4ine Case
NOTARY PUBLIC
New Hanover County
North Carolina
MY Co'r1n1iss10nS;8af August 8. 26! t
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Notary d
My commission expires b o