NCC221348_FRO Submitted_20220406

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. Evoke at Indian Trail
1. Project Name
2. Location of land -disturbing activity: County Union City or Township Indian Trail
Highway/Street Wesley Chapel stouts Rd Latitude 35.05124 Longitude-80.6424
3. Approximate date land -disturbing activity will commence: ,January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 25.12
1,690.00 $1,495 Previously Paid
6. Amount of fee enclosed: $ 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 Scott Bayer E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Evoke at Indian Trail, LLC 336-314-6169
Name Telephone Fax Number
2522 Suffolk Avenue 2522 Suffolk Avenue
Current Mailing Address Current Street Address
High Point, NC 27265 High Point, NC 27265
City State Zip City State Zip
10. Deed Book No. 7570 / 7898 Page No. 0889 / 0110 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.
Evoke at Indian Trail, LLC [e-mail]
Name E-mail Address
2522 Suffolk Avenue 2522 Suffolk Avenue
Current Mailing Address Current Street Address
High Point NC 27265 High Point NC 27265
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:
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:
Henry Rebisz [e-mail]
Name of Registered Agent E-mail Address
2522 Suffolk Avenue 2522 Suffolk Avenue
Current Mailing Address Current Street Address
High Point NC 27265 High Point
City State Zip City
Telephone.
E9191.1 El I[sx]P47:El!
Fax Number
NC 27265
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.
Henry Rebisz
Type or pr' t name
L4, CL
Si ature '`
Manager
Title or Authority
Date
1, Awla Notary Public of the County of r. • 6
State of North ling, hereby certify that appeared
personally before me this day and being duly- swor acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this _day of 20_
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