NCC221373_FRO Submitted_20220408

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. AMAVI AT SHERRILS FORD
1. Project Name
2.
Location of land -disturbing activity: County Catawba
Highway/Street Bradley Long Latitude 35.581130 _ Longitude-80.990613
Approximate date land -disturbing activity will commence: November 1, 2021
City or Township Hickory
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16.00 acres
6. Amount of fee enclosed: $ 1885 _. 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 $5885).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed V/
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Willie Morris E-mail Address [e-mail]
Telephone [phone] Cell # 843.327.6019 Fax # N/A
a
Landowner(s) of Record (attach accompanied page to list additional owners):
MCREF SFR 1 Sherrills Ford LLC N/A _ N/A
Name Telephone Fax Number
101 W Worthington Ave Suite 210 7821 BRADLEY LONG DR
Current Mailing Address Current Street Address
Charlotte NC 28203 SHERRILLS FORD NC 28673
City State Zip City
10. Deed Book No. 3494 Page No. 1781
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.
MCREF SFR 1 Sherrills Ford LLC [e-mail]
Name E-mail Address
1710 Camden Road 1710 Camden Road
Current Mailing Address
Charlotte NC 28203
City State Zip
[e-mail]
Current Street Address
Charlotte NC 28203
City State Zip
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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A 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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
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.
Type or print name Title or Authority
Signature Date
------------------------------------- ------ ---------------------- -------•--_---__----------------------------------------------------
I, ' SS b i V a Notary Public of the County of A&A""
State of North Carolina, hereby certify that / 11 I �TYA appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
16,
Witness my hand and,gy1frI91 seal, this day of f�%'9/G1/, , 20 Z -2—
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