NCC230737_FRO Submitted_20230321

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 Copper Ridge Estates
2. Location of land -disturbing activity: County LEE City or Township Deep River
Highway/Street Farrell Rd _ Latltude(decimal degrees) 35.575797 g ( -79.12147
Lon Rude decimal degrees)
3. Approximate date land -disturbing activity will commence: March 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential Subd.
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 19.8
6. Amount of fee enclosed: $ 2,000 . 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 p No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Johnny Byrd E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
SBM Homes, LLC 919-291-3637
Name Phone: Office # Mobile #
4191 FAYETTEVILLE RD., SUITE 100
Current Mailing Address Current Street Address
Raleigh, NC 27602
City State Zip City State Zip
10. Deed Book No. 1 676 Page No. 338 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 companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
SBM Homes, LLC
[e-mail]
Company Name E-mail Address
4191 FAYETTEVILLE RD., SUITE 100
Current Mailing Address Current Street Address
Raleigh, NC 27602
City State Zip City State Zip
Phone: Office # 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:
Juan Sanchez
[e-mail]
Name of Registered Agent
E-mail Address
4191 FAYETTEVILLE RD., SUITE 100
Current Mailing Address
Current Street Address
Raleigh, NC 27602
City State Zip
City State Zip
Phone: Office #
Mobile # [phone]
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
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)

(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.
Juan Sanchez
Type or print nam
Signatu
Agent
Title or Authority
0' -13 - &23
Date
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i, Saman+Q Uri be, Sc,yi llot , a Notary Public of the County of WeA ISt,
State of North Carolina, hereby certify that 7... 5e4 n r-,1,e--i 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 1 '"'day of t7ariu cti4 , 20 7--3
SAMANTA URIBE SEVILLA Notary
Notary Public, North Carolina
Wake County M commission expires J-U l Y its, ZOZ6
My Commission Expires Y {� .T..-1
July 18, 2026