NCC217093_FRO Submitted_20211221

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Noperson may initiate any land -disturbing activity onone ormore acres ancovered bythe Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality GooUon, N.C. Department of Environmental Quality, Submit the completed fwnn to the
appropriate Regional Office. (Please hypo or print and, if the question ianot applicable orthe e-mail and/
orfax information unavailable, place N/A inthe b|ank.)
Part A. K8O�OB�Ai�|S��UhH' 'S'O�-���B�8�
1. Project Name2. Location of land -disturbing activity: Count '^' Hills ' Subdivision ' Phase ~-
StaD|u
City orTownship Albemarle
'�0O��^e
I Highway/Street Morgan Road Latitude 35019'5393" Longitude 80012'3409"
3. Approximate date land -disturbing activity will commence: j@OU8rV^1 2022
����''����fB|
4. Purpose ofdevelopment (reoidenUoicommen�aiindua�aiinu�tu�una[e�.): residential
^
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 46.10
0. Amount of fee enclosed:3,055 The application fee of $05.00 per acre (rounded
uptothe next acre) iaassessed without oceiling amount (Examp|e:aQ-acnmapplication fee ia$585).
7. Has mnerosion and sediment control plan been filed? Yes No X�no|oaed�,�______
8. Person tncontact should erosion and sediment control issues arise during land -disturbing activity:
Name ]OhM8fh8O K4nCaU E-mail Address JmonoU@oanzina-dava|opmunLoom
91
Landowner(s) ofRecord (attach accompanied page tolist additional ownmr ):
BHR Land Holdings, LLC [phone]
Name Telephone Fax Number
4389 Indian Trail -Fairview Road 4389 Indian Trail -Fairview Road
Current Mailing Address
Indian Trail, NC 28079
City State
Current Street Address
Indian Trail, NC 28079
Zip City
State
Page No. 1202 Provide a copy of the most current deed.
Part B.
1Company(ieo) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list ofall responsible parties ononattached sheot)ff the ounpmnyorfirn/iyesole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
CaFO|'Ma Development Services ]O0CC@ll@C8[OliO@-dBV8lOp0OeO[OODl
Name
E-mail Address
2627 Breknn'dge Centre Drive
2627 Bpeknn'dOe Centre Drive
Current Mailing Address
Monroe, NC 28110
city
State Zip
Current Street Address
Monroe, NC 28110
City State
��M� 1�����
Telephone \'�-`/'"-" '=�� Fax Number
211

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 Current Street Address
City
Telephone
State Zip City
Fax Number
State Zip
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.
aJohnnn McCall
t name
IJ j
134'inature
1416191
Title or Authority
Date
a Notary Public of the County of Lkv-\,i o'�
State of North Carolina, hereby certify that olJ�^�-�� VYX. r-"�ca t 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 US
\\\jIIIiI///r
CO ®'C A F? Y
Seal
AUBl\G
r "01 C CU�� �\�\
1111100
day of 20 z-i
Notary'
My commission expires 3—Z--g" Z0 ZL 5