NCC223554_FRO Submitted_20221014

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.
1. Project Name Brighton Park Subdivision
2. Location of land -disturbing activity: County Cabarrus City or Township Mount Pleasant
Highway/Street NC Hwy 73 E Latitude 35-24-32 N Longitude 80-27-36 W
3. Approximate date land -disturbing activity will commence: June1 , 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 77 acres
6. Amount of fee enclosed: $ 7,700.00 The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
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 William Niblock E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
ECB LLC A North Carolina LLC
Name Telephone Fax Number
12416 Kluttz Road 12416 Kluttz Road
Current Mailing Address Current Street Address
Gold Hill NC 28071 Gold Hill NC 28071
City State Zip City State Zip
10. Deed Book No. 3758, 8179, Page No. 0037, 0002, Provide a copy of the most current deed.
8185, 8177 0021, 0282
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.
Niblock Homes, LLC [e-mail]
Name E-mail Address
759 Concord Parkway North -Suite 20
Current Mailing Address
Concord NC 28027
City
759 Concord Parkway North -Suite 20
Current Street Address
Concord NC 28027
State Zip City
State
Zip

Telephone [phone]
Fax Number
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:
Name
Current Mailing Address
C ity
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
William T. Niblock wniblockc niblockhomes.com
Name of Registered Agent E-mail Address
759 Concord Parkway North -Suite 20 759 Concord Parkway North -Suite 20
Current Mailing Address
Concord NC
City State
Telephone [phone]
Current Street Address
28027 Concord
Zip City
Fax Number
NC 28027
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 any change in the information provided herein.
William Niblock
Type or print name
Signature
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Title or Authority
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Date
I, f-rk Q t� yLA4mJ a Notary Public of the County of V-DO 1
State of North Carolina, hereby certify that w 1 JV6 M N),b1O6IL appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
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