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Home My WebLink AboutNCC221505_FRO Submitted_20220421Financial Responsibility/Ownership Form Sedimentation Pollution Control Ordinance No person may initiate any land -disturbing activity on one or more acres as covered by the ordinance before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Rowan County Environmental Management Department. Part A 1. Project Name COUNTRY CLUB VILLAGE T 2. Location of land -disturbing activity (Highway/Street) 0 HAWKINSTOWN ROAD Latitude 35.695818 3. Approximate date land -disturbing activity will be commenced 4/13/2022 Parcel ID Number 5761-04-51-6044 Longitude 80.463666 - ---- 4. Purpose of development (residential, commercial, industrial, etc.) RESIDENTIAL- — - 5. Approximate acreage of land to be disturbed or uncovered 26 ACRES I i 6. Person to contact should sediment control Issues arise during land -disturbing activity MATT MCPHERSON Email Address mmcpherson@smithdouglas.com Cell Phone Number 864-991-5079 7. Landowner of Record HDP COUNTRY CLUB VILLAGE LLC Name Landowner of Record Name Current Mailing Address Current Mailing Address 1316 SHERMAN AVE, #215 EVANSTON, IL 60201 $. Recorded in peed Book Number Page Number 1397 743 Part B 1. Person or Firm who are financially responsible for this land -disturbing activity SDH CHARLOTTE, LLC Name of Person(s) or Firm(s) Person or Firm who are financially responsible for this land -disturbing activity Name of Person(s) or Firm(s) Current Mailing Address Current Mailing Address 14297 HIGHWAY 24127 E SUITE B ,MIDLAND, NC 28107 Phone Number Phone Number 704-781-52224 - — — i a. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of a North Carolina Agent. Name of Agent Name of Agent Current Mailing Address Current Mailing Address Phone Number f" - Phone 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 the name and street address of the Registered Agent. Name of Registered Agent Current Mailing Address Current Street Address Telephone Number Telephone 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 authority to execute instruments for the Financially Responsible Person). I agree to provide correctional information should there be any change in the information provided herein. Name Title or Authority MATT MCPHERSON LAND ACQUISITION MANAGER Signature Date mm/ddlywy ................................................................................................................................................. 1, is , a Not Public of the County of CM � YY u $ State of North Carolina, hereby c rtify that Appeared personally before me this da} and being dul sworn acknowledged that the above form was executed by him/her. Witness my hand and seal of Notary. this —I& day of , 2o2Z Notary My commission expires mm/ddlyyyy DI /-Z-3 /7.0LLj "raniell/ C. . - - Co ,n Seal x` t�oTq g A - �BL1G , �/�Il ilulll YYYY•