NCC220843_FRO Submitted_20220222

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. Cannon 35
1. Project Name
2. Location of land -disturbing activity: County Clevland City or Township Kings Mountain
Margrace Road & 35.2132-81.3831
Highway/Street Kings Mountain Blvd. Latitude Longitude
3. Approximate date land -disturbing activity will commence: 12-01-2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential & Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 45.33
6. Amount of fee enclosed: $ 2,990 . 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 X Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name RD Harrell E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cannon 35 of KM LLC 704-564-4815
Name Telephone Fax Number
5615 Potter Road 5615 Potter Road
Current Mailing Address Current Street Address
Matthews, NC 28104 Matthews, NC 28104
City State Zip City State Zip
10. Deed Book No. 1813 Page No. 2743 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.
Cannon 35 of KM LLC [e-mail]
Name E-mail Address
5615 Potter Road
Current Mailing Address
Matthews, NC
City
5615 Potter Road
Current Street Address
28104 Matthews, NC 28104
State Zip City
Telephone [phone] Fax Number
State
Zip

Telephone [phone] 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 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 State Zip City State Zip
Telephone 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.
4RRELI, �t�
Type or print na e Title or Authority
F 1b t
Signature Date
I.A [0 0 io a Notary Public of the County of Mecoen6
State of North Carolina, hereby certify that . i ea � _ ryas � 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,
4p
a�l
this 1b day of s-l' , 20 2-1
Notary
My commission expires l d