HomeMy WebLinkAboutNCC222946_FRO Submitted_20220817FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project Name Emerson Hills Apartment Homes
2. Location of land -disturbing activity: County cabarrus City or Township Kannapolis
Highway/Street N. Ave. Extension Latitude N 35 27' 21° Longitude W 80 35' 56°
3. Approximate date land -disturbing activity will commence: 05/01/21
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off - site borrow and waste areas): 28.5AC*r
6. Amount of fee enclosed: $ 1885.00 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kara Strickland E-mail Address kstrickland@pedcor.net
Telephone (317) 218-2683 Cell # Fax #
E
Landowner(s) of Record (attach accompanied page to list additional owners):
Pedcor Investments, A Limited Liability Company 317.587.0320
Name Telephone
770 3rd Ave., S.W. 770 3rd Ave., S.W.
Current Mailing Address Current Street Address
Carmel IN 46032 Carmel IN
City State Zip
10. Deed Book No. 14707 Page
Part B.
City
State
317.587.0340
Fax Number
46032
Zip
0013-0027 Provide a copy of the most current deed.
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.
Pedcor Investments-2020-CXXIX, L.P. mbyron@pedcor.net
Name E-mail Address
770 3rd Ave., S.W. 770 3rd Ave., S.W.
Current Mailing Address Current Street Address
Carmel IN 46032 Carmel IN 46032
City State Zip City State Zip
Telephone
317.587.0320
Fax Number 317.587.0340
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:
McKenzie Pulicover
McKenzie.Publicover@kimley_horn.corn
Name
E-mail Address
200 Tryon St., Suite 200
200 Tryon St., Suite 200
Current Mailing Address
Current Street Address
Charlotte NC 28202
Charlotte NC 28202
City State Zip
City State Zip
704.333.5131
N/A
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 and street address of the Registered Agent:
Corporation Service Company
NIA
Name of Registered Agent
E-mail Address
2626 Glenwood Ave., Suite 550
2626 Glenwood Ave., Suite 550
Current Mailing Address
Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City State Zip
Telephone 800.927.9800 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.
Jared M. Houser Senior Vice President
Type or prin ame Title or Authori
4__iature Date
----------------------------- I -------------------------------------------------------------------------------------------------
I, {CFI ilVl Bynds , a Notary Public of the County of
rl
State of INVIt�E e Icj hereby certify that ���Y� i M Ski 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 *day of � _ 2020
P! ' CAITLIN BURGESS ['J
,o�pPY PG�f�` Notary Public, State of Indiana
=z SEAL;^= f3ooneCounty Notary
CommissionNumberNP0719538
p`?bin'k y Commission Expires
P.� M
April 02, 2027 My commission expires kn