NCC220848_FRO Submitted_20220223

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.G. 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. Broadmoor
1. Project Name
2. Location of land -disturbing activity: County Union City or Township Marvin
Highway/Street Waxhaw-Marvin Rd Latitude 35"04'12"N Longitude 80038'25.9"W
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 75.8
G. Amount of fee enclosed: $ 7,600.00 . 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? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Scott Morrison E-mail Address [e-mail]
Telephone Cell # 704-221-2532 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Brookfield Holdings (Broadmoor), LLC 602-451-4361
Name
250 Vesey St., 1 5th Floor
Current Mailing Address
New York, NY 10281
City State Zip
10. ❑eed Book No. 7292 Page No.
Telephone
250 Vesey St.,
Current Street Address
Fax Number
1 5th Floor
New York, NY 10281
City
903 and 907
State
Zip
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.
Beechwood Howey, LLC [e-mail]
Name
7621 Little Avenue, Suite 111
Current Mailing Address
E-mail Address
7621 Little Avenue, Suite 111
Current Street Address
Charlotte NC 28226 Charlotte NC
City
State Zip City
Telephone [phone]
Fax Number
State
Zip

2. (a) If the Financially Responsible Patty 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 ano st eet address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Telephone
state
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
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 change in the information provided herein.
Scott Morrison Project Manager
name
Signature
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