NCC240214_FRO Submitted_20240126

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 Environment and Natural Resources. (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 Joyner Park Town Homes
2. Location of land-disturbing activity: County Nash City or Township Rocky Mount
Highway/Street Bethlehem Rd Latitude 35 . 936828 Longitude —77 . 840257
3. Approximate date land-disturbing activity will commence: Summer 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 18 . 20 Acres
6. Amount of fee enclosed: $ 950 . The application fee of $50.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Zach Daugherty E-mail Address zdaugherty@gardenstreetcommunities. con
Telephone [phone] Cell# 910-548-8433 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
3.rden Street Communities Southeast, LLC 919-971-9772
Name Telephone Fax Number
100 W. Garden St, 2nd Floor
Current Mailing Address Current Street Address
Pensacola FL 32502
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Same as above
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Name E-mail Address
160 Mine Lake Ct,Ste 200 160 Mine Lake Ct,Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
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:
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
corrected information should there be any change in the information provided herein.
Garden Street Communities Southeast,LLC
William Bryan Adama Manager
Type or print name Title or Authority
l
S. 2r. ? o2,
igna ure William Bryan AdamS Date
I, trfu..,E3y ir-o -KPLAri- , a Notary Public of the County of A• vntii,rA
State o North�Ca aline, hereby certify that William Bryan Adams,manager appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. ^^ II
Witness my hand and notarial seal, this day of ✓LI►�� , 20 2S
t40-2 -- _: 7
Notary
Seal
` —,—— — — — — '- — My commission expires I . 2 •Z7
1 ;oi a P4... SHELLEY A SEPULVEDA 10
( .•_17, Notary Public-State of Florida
: Commission#HH 354309
` o;oF n My Comm.Expires Jan 25, 2027
t Bonded through National Notary Assn. )