NCC241117_FRO Submitted_20240412

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 Environment and Natural Resources. (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 Cabarrus Corners
2. Location of land-disturbing activity: County Cabarrus City or Township Concord
Poplar Tent& Huntersville-
Highway/Street Concord Road Latitude 35° 25' 23" N Longitude 80° 45' 20" W
3. Approximate date land-disturbing activity will commence: April 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): +l- 7 acres
6. Amount of fee enclosed: $ 455 . 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 erasion and sediment control issues arise during land-disturbing activity:
Name Scott Moore E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Skybrook, LLC [phone] [phone]
Name Telephone Fax Number
P.O. Box 38 6719-C Fairview Road
Current Mailing Address Current Street Address
Holly Springs, NC 27540 Charlotte, NC 28210
City State Zip City State Zip
10. Deed Book No. 06537 Page No. 0048 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attachedl_ sheet):
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Name E-mai Address
all 9 -C FFi►r ►/I CW C 7/ 9-e
Current Mailing Address Current Street Address
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City State Zip City State Zip
Telephone 'v�/- _ Sr—/0�0�' Fax Number 70 5' S.SD

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:1:::,2.►14,n/ CAC f a] p.,Ced veAr. ;G�
Name of Registered Agent E mai PAddress
6 719"'ITP�i z u GA
1 , F.( 61 i 9 -( 1 i✓)c w
Current Mailing Address Current Street Address
4 ,/,1/e / .,2&210 Chi,-%4 A,/e a2,,,2 i 0
City State Zip City State Zip
Telephone 70C/-.3 6s-/.24 Fax Number 7 —33 r— —fC
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 informationio should there be any change in the information provided- herein.
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Type orprint na. e Title or Authority
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Signature __- Date
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I, -)t? L,>, r y\ (y o t ++ , a Notary Public of the County of f\() N c kl (2,h(.S(t!/
State of North Carolina, hereby certify that )3i\ ) pi n . j(1i Lt 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 I Dom'day of At fl J i , 20
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NOTARY PUBLIC My commission expires rL't 1' ,,- ©!?&,
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