NCC220227_FRO Submitted_20220112

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. Heritage Subdivision
1. Project Name g
2. Location of land -disturbing activity: County Union City or Township Town of Indian Trail
Highway/Street Hawfield Road Latitude 35 01'34.30"N Longitude 80 40'04.48"W
3 Approximate date land -disturbing activity will commence: June 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 42.02
6. Amount of fee enclosed: 5 2,795.00 The application fee of $65.00 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameDavid Goracke Email Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
VK Heritage LLC
Name Telephone Fax Number W
14025 Riveredge Drive, Suite 175
Current Mailing Address Current Street Address
Tampa, FL 33637
City State Zip City State Zip
10. Deed Book No. 07243 Page No 304-308 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.
Kolter Land Partners, LLC [e-mail]
Name
105 N E 1 st Street
Current Mailing Address
Delray Beach, FL 33444
E-mail Address
Current Street Address
City State Zip City State
Telephone [phone] Fax Number
Zip

2. (a) If the Financially Responsible Parry is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Kolter Land / David Goracke
Name
9121 Anson Way, Suite 200
Current Mailing Address
Raleigh, NC 27615
City
Telephone
dgoracke _ kolter.com
E-mail Address
Current Street Address
State Zip City State Zip
919-868-6567 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
2626 Glenwood Avenue, Suite 550
Current Mailing Address
Raleigh, NC 27608
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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 attomey-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.
David Goracke
Type or print name
g;;c z_"-�
Signature
Vice President
Title or Authority
� _-
Date
I r-A UY AtjCr a Notary Public of the County of C of rvl s
State of North Carolina, hereby certify that _D p\VI d �llY Aowt 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 110�day of N �"� U 20 ?/i
Seal
KYRA SCHNEIDER
Notary Public, North Carolina
Cabarrus County
My Commission Expires
Is December 05, 2022
a
NotaryJ
My commission expires IZ 1 S� 1�1Z