NCC215207_FRO Submitted_20210916

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION o8moo7
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. VIDA 2 (Revision to CABAR-2017-074)
1. Project Name
2. Location of land -disturbing activity: CountylCabarrus City or TownshipKannapolis
Highway/Street200 S Maim Street Latitude35.49620200 Longitude-080.62547750
3. Approximate date land -disturbing activity will commence -July 2021
4_ Purpose of development (residential, commercial, industrial, institutional, etc.); Residential/Commercial
3.4 ACRES ORIGINALY PERMITTED
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 0.18 ACRES ADDITIONAL DENUDED
6. Amount of fee enclosed: $125 3.58 TOTAL DENUDED AREA
. The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No EnclosecL X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Peter Flotz E-mail [e-mail]
Telephone [phone] Cell # (321)-302-2930
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Kannapolis Master Venture, LLC (321)-288-6479
Name Telephone Fax Number
2420 E Sunrise Boulevard, #90 2420 E Sunrise Boulevard, #90
Current Mailing Address Current Street Address
Fort Lauderdale, FL 33304 Fort Lauderdale, FL 33304
city state zip City State zip
10. Deed Book No. (See Attached) Page No. (See Attached) 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Vida 2, LLC [e-mail]
Name E-mail Address
115 West Avenue 2420 E Sunrise Boulevard, #90
Current Mailing Address Current Street Address
Kannapolis NC 28081 Fort Lauderdale, FL 33304
City State Zip City state Zip
Telephone [phone] Fax Number n/a

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. -
Kent Gregory
kgregoryCOM9busa.com
NameofRegistered Agent
E-mail Address
115 West Avenue
115 West Avenue
Current Mailing Address
Current Street Address
Kannapolis NC 28081
Kannapolis NC 28081
City State
Zip city State Zip
Telephone [phone]
Fax Number n/a
(c) In 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:
LandDesign, Inc
[e-mail]
Engineering Firm or other consultant
E-mail Address
Aaron Wagoner, PE
704-333-0325 704-332-3246
Individual contact person (type or print)
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.
Kent Gregory Registered Agent
.f A
Type aj -
Ti
tle or Authority
8-521
Date
a Notary Public of the County of Ka�Q� U ls�
State of North Carolina, hereby certify that VI-en3c k-11reaOt" appeared personally
before me this day and being duly sworn acknowledged thatAe alOve form was executed by him.
4::Zkn
Witness my hand and notarial seal, this Q Clay of 20 V
Seal Notary
My commission expires�