NCC221183_FRO Submitted_20220331

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 NIA in the blank.)
Part A.
1. Project Name The Learning Experience - Harrisburg, NC
2. Location of land -disturbing activity, County Cabarrus City or Township Harrisbur
Highway/Street Jenkins Lane Latitude 35.321 Longitude 80.645
3 Approximate date land -disturbing activity will commence: 04/01/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial - Child Da care Center
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.92 ac.
6. Amount of fee enclosed: $ 130.00 . 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
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Doug Baumgartner E-mail Address [e-mail]
Telephone [phone] Cell # 704-877-3353
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Dobys 56 LLC
Name
14021 Conlan Circle, Ste. 10B
Current Mailing Address
Charlotte NC 28277
City
State Zip
704-542-7773
Telephone
Fax Number
14Q21.Cgnlan Circle, Ste. 108
Current Street Address
Charlotte NC 28277
City State Zip
10. Deed Book No. 12335 Page No. 0233-0238 Provide a copy of the most current deed.
Part B.
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.
Dobys 56 LLC _ doug [e-mail]
Name E-mail Address
14021 Conlan Circle, Ste. 10B 14021 Conlan Circle, Ste. 10B
Current Mailing Address Current Street Address
Charlotte NC 28277 Charlotte NC 28277
City State Zip City 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
Dobvs 56 LLC
Name
14021 Conlan Circle, Ste, 10a
Current Mailing Address
Charlotte NC 28277
City State Zip
Telephone [phone]
doug.baumgartner@yorkdevelopmentgroup com
E-mail Address
14021 Conlan Circle Ste. 10B
Current Street Address
Charlotte NQ 28277
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
1s a Corporation, give name and street address of the Registered Agent.
Doug Baumgartner
Name of Registered Agent
14021 Conlan Circle Ste. 1013
Current Mailing Address
Charlotte NC 28277
City
Telephone
State Zip
704-542-7773
doug.baumgartner@yorkdevelopmentgroup cam
E-mail Address
14021 Conlan Circle, Ste. 10B
Current Street Address
Charlotte NC 28277
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.
-DouQ Baumgartner
T e print name
1
Signature
Manager
Title for Authority
J/ a`'P0aP-
Date
I, , IL �� ` 1 . �x a Notary Public of the County of n4 Ptl)c11-61,
State of North Carolina, hereby certify that i�) o L( & [k I0 G tt -r T�v r appeared
personally before me this day and being duly sworn a knowledged thbit the above form was executed
by him.
eal, this day of }�'.� I I �� 20;,
NOTARY PUBLIC ✓�,j
Mecklenburg County
North Cirollna
M Cammisslan Expires Mar. 10, 2025
Notiiry [
Seal
My commission expires iN1Al - ' to