NCC215934_FRO Submitted_20211027

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Elan LoSo Owner LLC
Address: 521 E. Morehead Suite 400
Charlotte, NC 28211
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: 1� overka y'reystar.com
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax:
(Area Code)
Email Address:
(Area Code)
3. The above information is true and correct to the best of my knowledge and belief and was provided by me
while under oath. (This form must be signed by the financially responsible person if an individual or by an
officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the
financially responsible company or entity, if not an individual.)
Josh Glover
Name
Title
Vice President
3/2/21
Date
I, _�O'na C KUk n a Notary Public of the County
of U(1 I State of ��4h 00frrl�r�G�. hereby
certi that J USV 1 C U
personally
appeared before me this day and under oath acknowledge that this form was executed by hint/her.
Witness my hand and notyrial seal this Z day of 20 d
Notary Signature. -
My Commission expires
Notary Public, North Carolina
union County
my Commisslon Expires Page 2
U