NCC240235_FRO Submitted_20240125

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.1. Project Name Waterliegh Phase 5A Conservation Subdivision
2. Location of land-disturbing activity: CountyCUrrituCk City or TownshipMoyock
Highway/Street lulls Creek Rd Latitude 36.5167 Longitude-76.1415
3. Approximate date land-disturbing activity will commence:December 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):4'69
6. Amount of fee enclosed: $ 500 . 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 Enclosedx
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Terry Drew E-mail Address [e-mail]
Telephone [phone] CeII# 7574490613 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Waterleigh NC, LLC 757-563-5000
Name Telephone Fax Number
448 Viking Dr. Ste 220
Current Mailing Address Current Street Address
virginia Beach VA 23452
City State Zip City State Zip
10. Deed Book No. Page No. 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 maybe listed as the financially responsible party.
Chesapeake Homes of North Carolina Inc. [e-mail]
Name E-mail Address
448 Viking Dr. Ste 220 same as mailing
Current Mailing Address Current Street Address
Virginia Beach, VA 23452
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:
CT Corporation System
Name of Registered Agent E-mail Address
160 Mine Lake Ct. Ste 200 same as mailing
Current Mailing Address Current Street Address
Raleigh NC 27615-6417
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
corrected information should there be any change in the information provided herein.
Raymond Gottlieb Manager} y,/A{„2 ,5,4 i
Type or print aier>,/� Title or Authority
l
Signature Date
I, U�c_A_,L, Ct.AcLA , a Notary Public of the County of la Z,2c.c.JJ.,
V i r s•\�lcam�}.a-�
State of North Car-el•ina, hereby certify that Q...t/wra,na 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 Lo4 ' day of '-f(t -- 20 .3
comma L Hardin Notary
• i �of Virpints
Combk mission No.I377581 My commission expires t a rat -2 L
_., My Commission Expfres 124112026