NCC216456_FRO Submitted_20211123

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.
a
Project Name
Location of land -disturbing activity: County Cabarrus City or Township Concord
Highway/Street Quay Road Latitude 35.364909 Longitude-80.718669
Approximate date land -disturbing activity will commence: February 1. 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.34
Amount of fee enclosed: $ 650.00 . 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).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Steve Raccuglia E-mail Address sraccuaIia(a)roomstoao.com
Telephone [phone] Cell #
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Concord -Oriole LLC, a Delaware
Limited Liability Company
Name Telephone
11540 Highway 92 East 8520 Quay Road
Current Mailing Address Current Street Address
Fax Number
Seffner FL 33584 Concord NC 28027
City State Zip City State Zip
10. Deed Book No. 13974 Page No. 0041 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible Darties on an attached sheet):
Concord -Oriole LLC, a Delaware Limited
Liability Company - Peter Weitzner pweitznera-roomstogo.com
Name E-mail Address
4004 Summit Boulevard Northeast Ste 600 4004 Summit Boulevard Northeast Ste 600
Current Mailing Address
Atlanta GA 30319
City State Zip
Telephone [phone]
Current Street Address
Atlanta GA 30319
City State Zip
Fax Number 770-352-9953

Landowners) of Record (attach accompanied page to list add'dtional owners):
Concord -Oriole LLC, a Delaware
Limited Liability Company
Name Telephone Fax Number
11540 Highway 92 East
Current klaiiiny Address
Seffner FL 33584
City State Zip
10. Deed Book No. 13974 Page No. 006
8520 Quay Road

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:
Name of Registered Agent E-mail Address
Current Mailing Address
City
Telephone.
Current Street Address
State Zip 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 information should there be any change in the information provided herein.
Peter Weitzner President
or print name
Title or Authority
s [� a
Date
I, _q / r i 71; ro a Notary Public of the County of tie.1<t ( b
State of a, hereby certify that ��+2 r k)oj2 A 8 appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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g
Witness my hand and notarial seal, this �ds
My commission expires,
a o a).