NCC241145_FRO Submitted_20240416

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.)
P1.art AProject Name Davis Village
2. Location of land-disturbing activity: County Union City or Township Wingate
Highway/Street Phlfer Road Latitude 34.9927 Longitude-80.4259
3. Approximate date land-disturbing activity will commence: 1 1/1/23
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 56.0
6. Amount of fee enclosed: $ already paid . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Cody E-mail Address Simoneaux
Telephone [phone] Cell# 704.840.8362 Fax# n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MI Homes of Charlotte, LLC. 704.597.4538 n/a
Name Telephone Fax Number
5350 77 Center Drive, Suite 100
Current Mailing Address Current Street Address
Charlotte, NC 28217
City State Zip City State Zip
10. Deed Book No.08796 Page No.0152 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.
MI Homes of Charlotte, LLC. [e-mail]
Name E-mail Address
5350 77 Center Drive, Suite 100
Current Mailing Address Current Street Address
Charlotte, NC 28217
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:
Corporation Service Company
Name of Registered Agent E-mail Address
2626 Glenwood Av, Ste. #550 2626 Glenwood Av, Ste. #550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
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.
ySI Plonet,020
Type od pri t name Title or Authority
Signat re Date
l Rai ,cot Mair\VA.4-) a Notary Public of the County of Me,Gk `eir 1 Y./Uf
State of North Carolina, hereby certify that C t)a Wm .1\ appeared
personally before me this day and being duly s orn acknowledged that the above form was
executed by him.
Witness my han`skopc,nrotarial seal, this_ day of � (AC , 20 2�
.\`GG A M O,y`'I,/
.•'p0 M M�°., t�� 'moo10/ \C\
cc JANUARY 16,<, _ = Notary
al 2025 My commission expires 1 u, ld(Jl \, \p 1?i0/j
y P \a
',Jot