NCC240194_FRO Submitted_20240123

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. Lotus Ridge
1. Project Name
2. Location of land-disturbing activity: County Currituck City or Township Moyock
Puddin Ridge Rd (SR1216) 36.499 -76.192
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence:November 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 240
6. Amount of fee enclosed: $ 24,000.00 . 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 Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Perry Arnette E-mail Address [e-mail]
Telephone[phone] cell # [phone] Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
FPI Carolinas, LLC
Name Telephone Fax Number
4600 South Syracuse St. Suite 1450 4600 South Syracuse St. Suite 1450
Current Mailing Address Current Street Address
Denver CO 80237 Denver CO 80237
City State Zip City State Zip
10. Deed Book No. 1329 Page No. 67 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.
Puddin Ridge AP, LLC [e-mail]
Name E-mail Address
417 Caratoke Hwy, Unit D 417 Caratoke Hwy, Unit D
Current Mailing Address Current Street Address
Moyock NC 27958 Moyock NC 27958
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Allied Properties, LLC do Justin Old [e-mail]
Name of Registered Agent E-mail Address
417 Caratoke Hwy, Unit D 417 Caratoke Hwy, Unit D
Current Mailing Address Current Street Address
Moyock NC 27958 Moyock NC 27958
City State Zip City State Zip
Telephone[phone] 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
corrected information should there be any change in the information provided herein.
SE-1- A/c-x% PAC,
Type or print name Title or Authority
Signature Date
I, , a Notary Public of the County of
State of North Carolina, hereby certify that 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
Notary
Seal
My commission expires

(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 assisfin providing any necessary information regarding the plan and its preparation:
Engineering firm or other consultant E-mail Address
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.
n'os-v /U D 1 _^�lb'N1 Of 2
Type or print nam Title or Authority
9 . 2t0.2-
ignature Date
I, IA: ht1CLI- , a Notary Public of the County of 1
ZState of h Carolina, hereby certify that UA J4 Gt, appeared personally
before me this day and being duly sworn ackn Medged that the above form was executed by him/her.
Witness my hand and notarial seal, this 26-, day of , 20 23
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o �' Notary
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NOTARY
Seal U _ I I My commission expires V L 7 12023
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