NCC233783_FRO Submitted_20240110

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. Northlake Phase 3
1. Project Name
2. Location of land-disturbing activity: Countylredell City or TownshipStateSVllle
Highway/Street Mountain Island Drive Latitude _ _ Longitude
3. Approximate date land-disturbing activity will commence: -
4. Purpose of development(residential, commercial, industrial, institutional,etc.):Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):5.21'
100.00 . The application fee of$100.00 per acre
6. Amount of fee enclosed: $ pp�
(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? YesX No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Keith Ferguson E-mail [e-mail]
Telephone[phone] Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Adams Homes AEC, LLC 850-934-0470
Name Telephone Fax Number
100 W. Garden Street, 2nd Floor
Current Mailing Address Current Street Address
Pensacola, FL 32502
City State Zip City State Zip
10. Deed Book No.BK3001 Page No.1490-1492 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 company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Adams Homes AEC, LLC [e-mail]
Name E-mail Address
100 W. Garden St., 2nd Floor 100 W. Garden St., 2nd Floor
Current Mailing Address Current Street Address
Pensacola, FL 32502 Pensacola, FL 32502
City State Zip City State Zip
Telephone [phone] 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:
National Registered Agents, Inc. Privacy Redaction
Name E-mail Address
160 Mine Lake Ct., Ste. 200 same
Current Mailing Address Current Street Address
Raleigh, NC 27615
City State Zip City State Zip
Telephone Privacy Redaction 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone _ 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
corrpcted information should there be any change in the information provided herein.
*mitts. 91meg'Psi i.i.t.
Bryan Adams Manager
Type or print name Title or Authority
12/08/23
Signature Date
1, Shelley A. Sepulveda , a Notary Public of the County of Escambia
State of North Carolina, hereby certify that Bryan Adams, Manager 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 8 day of December , 2023
4'ii r'o' SHELLEY A SEPULVEDA -_
"; --; Notary Pub4ic.State of Florida Chi
.Commission#NH 354309
Comm.Expires Jan 25,2027 1/25/27
..Bonded through National Notary Assn. My commission expires