NCC231788_FRO Submitted_20230608

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Brookside Subdivision— Lots 1 & 2
2. Location of land-disturbing activity: County Moore City or Township_Mineral Springs Township
Carthage Road
Highway/Street SR-1229 Latitude)decimal degrees) N 35.2551° Longitude)decimal degrees) W-79.5554'
3. Approximate date land-disturbing activity will commence: June 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.16 Acres
6. Amount of fee enclosed $300.00 Normal + $750.00 Express. The Express Permitting application fee is a
dual charge. The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a
ceiling amount. In addition, the Express Permitting supplement is $250 per acre up to eight acres,
after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre
application fee is $2,900). Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Leanna Hair E-mail Address leannahair(a�onsitehomesnc.com
Phone: Office# 910-745-0001 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Flynn-Fletcher, LLC
Name Phone: Office# Mobile#
355 E New York Avenue Same
Current Mailing Address Current Street Address
Southern Pines NC 28327 Same
City State Zip City State Zip
10. Deed Book No. 5916 Page No. 010 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).
Onsite Homes, LLC nedjohnsononsitehomesnc.com
Name E-mail Address
2919 Breezewood Avenue, Suite 300 Same
Current Mailing Address Current Street Address
Fayetteville NC 28303 Same
City State Zip City State Zip
Phone: Office# 910-745-0001 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:
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)
(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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Moorman, Kizer& Reitzel, Inc. dgilbert(cmkrinc.com
Engineering firm or other consultant E-mail Address
Dennis A. Gilbert 910-484-5191
Individual contact person (type or print) Phone: Office# Mobile#
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.
Nathaniel Johnson'.\ Managing Member
Type or print name Title or Authority
t___..__ §40/2.3
Signature Date
I, - 1l/r lCt-I V,CJ , a Notary Public of the County of6Ambfao-Ad
State of North Carolina, hereby certify that /aV--rA4Alth'r— appeared
personally before me this day and being duly sworn acknowled&d that the above form was
executed by him/her.
366
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Witness my hand and notarial seal, this day of 20 2
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? 2 i Q= mmission expires (0/42 r7
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