NCC223154_FRO Submitted_20220908

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity (Note: If the financially responsible
person(s) or firm(s) has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: Cardinal Development Group - Charles Kieler
Address: 8320 Judy Whit Lane
Telephone:
Vienna, VA 22182
517-239-0615
(Area Code)
Email Address: ckiele
inaldevgrp.com
Fax:
(Area Code)
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina agent:
Person or Firm: Bohler Engineering NC, PLLC
Address: 1927 S. Tryon Street, Ste. 310
Charlotte, NC 28203
Telephone: [phone]
ax:
980-272-3401
(Area Code) (Area Code)
Email Address: [e-mail]
3. The above information is true and correct to the best of my knowledge and belief and was provided by me
while under oath. (This form must be signed by the financially responsible person if an individual or by an
officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the
financially responsible company or entity, if not an individual.)
(�� E� t� �1115�1 - /P
Printed Name Title / r
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Signature Date
1,
Of -
certify
that,
SeYe
M
a Notary Public of the County
State of Wr hereby
K. k% & ( P 8- personally
appeared before me this day and under oath acknowledge that this form was executed by him/V.
Witness my hand and notarial seal, this day a.` 6'9
Notary Signature:
My Commission expires:
.11 J 0 Z
charfottenc.gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
htip://charlottenc.gov/developiietit center
20_2- l
Page 2
Rev.09/2021