NCC216913_FRO Submitted_20211214

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A. Calamar Settlers Landin
1. Project Name 9
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Highway/Street 3575 Jacobs crossing Blvd Latitude 35.3720 Longitude-80.6620
3. Approximate date land -disturbing activity will commence: 1 1 /16/21
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Senior Living Community
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.06
6. Amount of fee enclosed: $ 390.00 . 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).
7. 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 Bethany Peck E-mail Address [e-mail]
Telephone [phone] Cell # 7048868132 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Settlers Landing Commercial LLC
Name Telephone Fax Number
215 Milford Cir 215 Milford Cir
Current Mailing Address Current Street Address
Mooresville NC 28117 Mooresville NC 28117
City State Zip City State Zip
10. Deed Book No. 12866 Page No. 0107 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.) lithe company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Peck & Sons Inc [e-mail]
Name E-mail Address
2296 Miami Church Rd
Current Mailing Address
Concord NC 28025
City State Zip
Telephone [phone]
2296 Miami Church Rd
Current Street Address
Concord NC 28025
City State Zip
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:
Name
Current Mailing Address
City
Telephone,
E-mail Address
Current Street Address
State Zip 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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
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 attomey-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.
Bethany Peck Owner/CEO
Type or print name
2M2�= A C41-
Signature
Title or Authority
12-7-21
Date
I, rz{- , a Notary Public of the County ofGt/L'�
State of North Carolina, hereby certify that _ _r_ e C11fl- appeared
personally before me this day and being duly sworn ack owledged that the above form was
executed by hire.
Witness my hand S nO notarial seal,
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