NCC240363_FRO Submitted_20240214

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 NameJackson Hole lots 5,6,and 7
2. Location of land-disturbing activity: CountyUnion City or TownshipWaxhaw
Rehobeth 34.89 -80.76
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence:
2/15/2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):.87 acres
6. Amount of fee enclosed: $ 100.00 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosedx
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ben Russell E-mail Address [e-mail]
Telephone[phone] Cell# 7042913150 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Pinnacle Homes USA LLC 7042913150
Name Telephone Fax Number
4389 Indian Trail Fairview RD same
Current Mailing Address Current Street Address
Indian Trail NC 28079 same
City State Zip City State Zip
10. Deed Book No.7743 Page No.294 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.
Pinnacle Homes USA LLC [e-mail]
Name E-mail Address
4389 Indian Trail Fairview Rd same
Current Mailing Address Current Street Address
Indian Trail NC 28079 same
City 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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:
Benjamin Russell [e-mail]
Name of Registered Agent E-mail Address
4389 Indian Trail Fairview Rd same
Current Mailing Address Current Street Address
Indian Trail NC 28079 same
City State Zip City State Zip
Telephone[phone] Fax 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
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.
Ben Russell Owner
Type or print name Title or Authority
— L
Sigriatu a Date
Jennifer Trull , a Notary Public of the County of Union
State of North Carolina, hereby certify that Ben Russell 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 14th day of January 2022
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