SW3180606_6198 Financial Responsibility Form Updated_20181107

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 Cavesson
2. Location of land -disturbing activity: County Union City or Township Wesley Chapel
Highway/StreetChambwood Rd Latitude34d59'35.1"N Longitude80d40'35.3W
3. Approximate date land -disturbing activity will commence: November 1, 2018
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.9 aC
6. Amount of fee enclosed: $ 1040.00 (16 ac) 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 X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name T. J. Pecorak E-mail Address [e-mail]
Telephone [phone] Cell # 703-304-0391 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mark J & Kate K Rosenblum
Name Telephone Fax Number
703 Chambwood Rd same
Current Mailing Address Current Street Address
Monroe NC 28110
City State Zip City State Zip
10. Deed Book No. 550 Page No, 851 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 attached sheet):
Bowman Development Group [e-mail]
Name E-mail Address
13815 Cinnabar Place same
Current Mailing Address Current Street Address
Huntersville NC 28078
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:
NIA
Name
Current Mailing Address
City State
E-mail Address
Current Street Address
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:
Robert Bowman
Name of Registered Agent
E-mail Address
same
Current Street Address
City State Zip
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 informationshould there be any change in the information provided herein.
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Type or print name Title or Authority
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gnat3ure� Date
,a,�NotaryPublicoftheCountyof 11AS-toN
State of North Carolina, hereby certify that \LngcCT S3ot.,uwN 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 0huct wn•oFa , 20V_
P SMjtN/i.
Seal _ Notary Public
Gaston County
Notary
My commission expires 3 23.2Ot9