NCC216709_FRO Submitted_20211203

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 Name_Encore at Streamside
_
a
3.
4.
5,
6.
I0
Location of land -disturbing activity: County Union City or Township Waxhaw
Highway/Street Cuthbertson Road Latitude 34.957495 Longitude-80.748612
Approximate date land -disturbing activity will commence: Apri I 1, 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 89 AC + 3.32 AC
5,785 paid + $260 included
Amount of fee enclosed: $ . 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 X _ _ No. Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Scott Kilby E-mail [e-mail]
Telephone [phone] cell # 704-905-1831 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
DRP NC 1, LLC 212-751-5969
Name Telephone
6900 E. Camelback Road, Suite 906
Current Mailing Address Current Street Address
Scottsdale AZ 85251
City
10. Deed Book No. 7931
State
Zip City
Page No. 0478
Fax Number
State
Zip
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.
Classic Neighborhood Development, LLC sboling a► dwhomes.com
Name E-mail Address
1111 North Post Oak Road
Current Mailing Address Current Street Address
Houston TX 77055
City State
Telephone [phone]
Zip City
Fax Number
State
Zip

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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
(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:
Corporation Service Company [e-mail]
Name of Registered Agent
2626 Glenwood Ave., Suite 550
Current Mailing Address
Raleigh NC 27608
City
State Zip
Telephone [phone]
E-mail Address
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 information should there be any change in the information provided herein.
Shannon Boling
Type or print e
Signature
Land Acquisition Manager
Title or Authority
D% Z-1
Date
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I, `� �' _ a Notary Public of the County of
State of North Carolina, hereby certify that st��flt A-0 6;r s 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 v` ? day of , 20 a 1
V
Seal
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a C��
Notary
My commission expires