NCC221281_FRO Submitted_20220404

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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. Stadium Lofts (block 4A and 413)
1. Project Name
2. Location of land -disturbing activity: County Cabarrus city orrownshipKannapolis
Highway/street West Avenue Latitude 35.49819 Longitude-80.62589
3. Approximate date land -disturbing activity will commence: January 15, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential/Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.31 Acres
6. Amount of fee enclosed: $ 700 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 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 $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Peter Flotz E-mail Address [e-mail]
Telephone [phone] cell # (321)-302-2930 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Right Field Development 321.302.2930 n/a
Name Telephone Fax Number
c/o Lansing Melbourne Group 101 PIE 3rd Avenue Suite 1500 clo Lansing Melbourne Group 101 NE 3rd Avenue Suite 1500
Current Mailing Address Current Street Address
Ft Lauderdale FL 33301 Ft Lauderdale FL 33301
City State Zip City State Zip
10. Deed Book No. Page No. 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 orfrrm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Right Field Development, LLC [e-mail]
Name E-mail Address
c/o Lansing Melbourne Group 101 NE 3rd Avenue Suite 1500 c/o Lansing Melbourne Group 101 NE 3rd Avenue Suite 1500
Current Mailing Address Current Street Address
Ft Lauderdale FL 33301 Ft Lauderdale FL 33301
City State Zip City State Zip
Telephone [phone] X 141140 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:
Peter Flotz [e-mail]
Name 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
(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:
Peter Flotz [e-mail]
Name of Registered Agent E-mail Address
115 West Avenue
Current Mailing Address Current Street Address
Kannapolis NC 28081
City State Zip City State Zip
Telephone [phone] Fax Number
(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:
Land Design, Inc. [e-mail]@landdesign.com
Engineering Firm or other consultant E-mail Address
Aaron Wagoner/Jessica Hoffman 704-333-0325
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.
Peter Flotz Managing Member
me 12.21.21 Title or Authority
;7�r2p'2,�,a
S' ture Date
I, �1 1,6 �4 e S' u , a Notary Public of the County of
t` I J
State of ,hereby certify that . �`rf 0, 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 _l day of \j BAN c)A ,�q , 20 L7i
in L C" ,
oti'pY iy .. DIANE SIUMAX
Notary Public - stile Of Florida Notary
i� Commission M GG 315431
My Comm. Expires mar 24, 2023 My commission expires
Banded through uatior9l Notuy Assn.