NCC220656_FRO Submitted_20220211

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. The Courtyards on Robinson Church
1. Project Name y
2. Location of land -disturbing activity: County Cabarrus City or Township Harrisburg
Highway/Street Robinson Church Latitude 35.307 Longitude-80.656
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 32.14
6. Amount of fee enclosed: $ 2,145.00 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andy Gibbon E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Epcon Robinson Church, LLC [phone]
Name Telephone Fax Number
500 Stonehenge Parkway
Current Mailing Address Current Street Address
Dublin, OH 43017
City State Zip City State Zip
10. Deed Book No. 1 5067 Page No. 0085 Provide a copy of the most current deed.
10art Bs '
1. Company(ies) or firm(s) who are: financially-Fesgonsible for the land -disturbing activity (Provide a
comprehensive list of ah'respohsible 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.
Epcon Robinson Church, LLC [e-mail]
Name i' " �� E-mail Address
2626 Glenwood Ave., Suite 550
Current.,Mailing Address Current Street Address
Raleigh, NC 27608
City- , ' State
Telephone [phone]
Zip 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:
Andy Gibbon, Land Development Manager [e-mail]
Name E-mail Address
11020 David Taylor Drive, Suite 105
Current Mailing Address
Charlotte, NC 28262
City State
Telephone [phone]
Current Street Address
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 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.
Type or rint name Title or Authority
k�lk 9 j
Signatur Date
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I, Qom, . cj_ , a Notary Public of the County of h er-1
State of North Carolina hereby certify that �� 'k)"' appeared
personally before me this day and being duly sworn I acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this % �" day of , 20oq
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4.% 104� Notary
G6, 9,Q My commission expires —
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