NCC231787_FRO Submitted_20230608

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 Osprey Isle, Phase 1
2. Location of land-disturbing activity: County Brunswick City or Township Highway/Street US-17 Latitude(decimal degrees)33.95 Longitude(decimal degrees)-78.47
3. Approximate date land-disturbing activity will commence: 3/1/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):42.5
6. Amount of fee enclosed: $4,300 . 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Walter Warren, PE E-mail Address [e-mail]
Phone: Office# 843-839-3545 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
T & W 142 LAND TRUST LLC
Name Phone: Office# Mobile#
5320 BRIDGERS RD
Current Mailing Address Current Street Address
SHALLOTTE, NC 28470-4736
City State Zip City State Zip
10. Deed Book No.04784 Page No. 0586 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 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).
Lennar Carolinas, LLC [e-mail]
Company Name E-mail Address
1941 Savage Road, Ste 100C same
Current Mailing Address Current Street Address
Charleston SC 29407 same
City State Zip City State Zip
Phone: Office# 704-975-0887 Mobile#
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:
Coporate Creations Network, Inc.
Name of Registered Agent E-mail Address
700 NW 107th Ave, Ste 400 15720 Brixham Hill Avenue #300
Current Mailing Address Current Street Address
Miami, FL 33172 Charlotte, NC 28277
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 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)

i
(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 hould there be any change in the information provided ein.
r-M.E, .1-- _ \..)?
Type or •rint n- e Title or Authority
,�, ct (a - t.a4),
Sign- e Date
I, alk` , /A �jjt E , a Notary Public of the County of (IH t"Cd���APL-a-c
illiP
State of North Carolina, hereby certify that 0-7A13 L l 1 - 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 47 day of SEPT ,& , 20
Ene__- .
Notary
My commission expires E5A.7/
DEBRA JONES
Notary Public,Mite o South Campos
My Comm sslan Expires 8127f2023

Continued from Items 9 & 10 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:
COLASANTI ARTHUR RICHARD 704-953-2928
Name Phone: Office# Mobile#
1469 REGATTA LN SW same
Current Mailing Address Current Street Address
OCEAN ISL BCH, NC 28469-6187
City State Zip City State Zip
Deed Book No.04298 Page No. 0714 Provide a copy of the most current deed.
Landowner 3 of Record:
COLASANTI ARTHUR RICHARD ETUX COLASANTI MARGO 704-953-2928
Name Phone: Office# Mobile#
1469 REGATTA LN SW same
Current Mailing Address Current Street Address
OCEAN ISL BCH, NC 28469-6187
City State Zip City State Zip
Deed Book No.04550 Page No. 1027 Provide a copy of the most current deed.
Landowner 4 of Record:
T & W 142 LAND TRUST LLC 843-222-1494
Name Phone: Office# Mobile#
5320 BRIDGERS RD same
Current Mailing Address Current Street Address
SHALLOTTE, NC 28470-4736
City State Zip City State Zip
Deed Book No.04907 Page No. 1209 Provide a copy of the most current deed.
Landowner 5 of Record:
Carolyn Skipper Strickland 910-791-6459
Name Phone: Office# Mobile#
649 Julia Drive same
Current Mailing Address Current Street Address
Wilmington, NC 28412
City State Zip City State Zip
Deed Book No. 3943 Page No. 97 Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#