NCC231078_FRO Submitted_20230419

2/2123, 2:02 PM
Rowan County
Financial 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*
.iberty Grove
2. Location of land -disturbing activity (Highway/Street)*
L Liberty Street, China Grove, NC
Latitude
Longitude
35.567673-80.569069
3. Approximate date land -disturbing activity will be commenced
11 /28/22
4. Purpose of development (residential, commercial, industrial, etc.)
residential
5. Approximate acreage of land to be disturbed or uncovered*
6. Person to contact should sediment control issues arise during land -disturbing
activity*
Noah Gordon
*this Information will be made available on the Rowan County Planning & Development website.
Email Address
[e-mail]
Parcel ID Number
124-102, 124-046, 124-
061, 124-019
Cell Phone Number*
732-364-1900
https:llwww.rowancountync.gov/FormCenterlPrint?formlD=96&Preview=YES$Save=False&savedProgresslD= 1/3

2/2/23, 2:02 PM
7. Landowner of Record
Rowan County
Landowner of Record
Platinum NC LLC
i
Name
Current Mailing Address
210 Ocean Ave
Lakewood, NJ 08701
8. Recorded in Deed Book Number
1413
Part B
1. Person or Firm who are financially responsible for this
land -disturbing activity
Platinum NC LLC
Name of Person(s) or Firm(s)
Current Mailing Address
210 Ocean Ave
Lakewood, NJ 08701
Phone Number
732-364-1900
i
Name
Current Mailing Address
Page Number
675
Person or Firm who are financially responsible for this land -
disturbing activity
i
Name of Person(s) or Firm(s)
Current Mailing Address
Phone Number
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
Business Filings Incorporated
Name of Agent
Current Mailing Address Current Mailing Address
160 Mine Lake Ct. Suite 200
Raleigh, NC 27615
Phone Number Phone Number
718-878-5811
https://www.rowancountync.gov/FormCenter/Print?formlD=96&Preview=YES&Save=False&savedProgresslD= 2/3

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Rowan County
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
I L
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
Noah Gordon Managing Member
Signature Date
mm/ddlyyyy
n31�-�12�4.3
I, !Zli-lA.11 o\t,�t-fir'- a Notary Public of the County of (°i — State of North Carolina,
hereby certify that o,. " (n,.,i i.. appeared personally before me this day and being duly sworn acknowledged
that the above form was executed by him/her. Witness my hand and seal of Notary, this day of IA ,vN , 2013
Notary My commission expires
mm/dd/yyyy,
/ // p312g12D23
i
Seal
Checklist
Download a copy of the Erosion and Sedimentation
Control Plan Checklist (PDF)
rCHE'
MTr
ERYLGOLDBRENNERNOTARY PUBLICOFNEW JERSEY
MISSION EXPI ES Marcch 8, 2026
hops:l/www.rowancountync.gov/FormCenterlPdnt?formlD=96&Preview=YES&Save=False&savedProgresslD= 3/3