NCC223485_FRO Submitted_20221012

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. Paxon Property
1. Project Name
2. Location of land -disturbing activity
Highway/Street Stella Road
Count Carteret
City or Township Stella
Latitude34.790 Longitude-77.143
3. Approximate date land -disturbing activity will comme
October 3, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):5.0
6. Amount of fee enclosed: $ 500 . 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
IV
rr
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Robin Comer E-mail [e-mail]
Telephone[phone] Cell # 252-725-0548 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Robin and Donna Comer 252-725-0548
Name Telephone
322 C Wood Farms Road
Current Mailing Address
Swansboro, NC 28584
City State
10. Deed Book No.1771
Current Street Address
Zip City
Page No.037
Fax Number
State
Zip
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 companyorfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Robin and Donna Comer coastalcomers [e-mail]
Name E-mail Address
322 C Wood Farms Road
Current Mailing Address
Swansboro, NC 28584
City State
Telephone [phone]
Current Street Address
Zip City State Zip
Fax Number

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:
Name of Registered Agent
Current Mailing Address
City State
Telephon
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
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.
Robin
Property Owner
or print na Title or Authority
0 A Z
Date 1.
a Notary Public of the County of �(y 1 XO
State of North Carolina, hereby certify that Rjh1C1 C`( CI appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. ��'"
Witness my hand and notarial seal, this _day of �, 20 22
Fosfi5l* OTAR Notary
Seal
PUBL\G = My commission expires 11 20 2
.,,RFT Cov ��•