NCC232896_FRO Submitted_20230927

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: Moore Farms Phase III
2. Location of land-disturbingactivity: Count Union Cityor Township: Indian Trail
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Highway/Street: Waxhaw-Indian Trail Road Latitude: Longitude:
3, Approximate date land-disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 75 AC
6. Amount of fee enclosed: $7500.00 . The application fee of $100.00 per acre (rounded up to the
next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
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7. Has an erosion and sediment control plan been filed? Yes I 1 No __ Enclosed
8. Person to contact should erosion and sediment control issues arise duringin land-disturbing activity: \
Name: �-)41-r (ALL o� E-mail Address: •5& T C.7— 6N`NC-C &
Telephone: 'lDJ 110 6 Cell #:104 `1 Fax #:
9. Landowner(s) of Record:
See attached*
Name Telephone Fax Number
Current Mailing Address Current Street Address
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):
Baybridge Moore Farm, LLC [e-mail]
Name E-mail Address
8905 Primula Drive 8905 Primula Drive
Current Mailing Address Current Street Address
Gaithersburg MD 20882 Gaithersburg MD
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:
Ste C v Lo ��' Z D��i PVC_ 6E:44,4
Name E-mail Address
( 1--3_k ft NI ee ,5 4-
Current Mailing Address Current Street Address
G )c -+ M 2603
City r State Zip City State Zip
Telephone -/d"—q Ls-- Let9$ (4. 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:
t ll C '4-t—'--'aa w i < , @ C 2 6 t -- /Q C _ C,n 1k*
Name of Registered Agent E-mail Address
L3 J—i P.S (26-4n s 4
Current Mailing Address Current Street Address
fN 1r C �g173
City State Zip City State Zip
Telephone: -7 Ci --qb Fax 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.
,,g, D. c_. Manager _
Type or pri .. Title or Authority
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Signatur Date
H , a Notary Public of the County of LEG
State of , hereby certify that 193 (Aia F-09-tE' appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. II �, nn
Witness my hand and notarial seal, this I . day of K4 KL , 20 L-
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:1i!"auk•. THIm,D RJHLAND 1/7u r
;C.; ;,t Notary Public-State of Florida
IH,�,yg Commission#NH 062788 N tary
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Bonded throu0 National Notary Assn- My commission expires J IV ,5 6 u 6