NCC223806_FRO Submitted_20221114

FINANCIAL RESPONSIBILITY1OWNERSHIP 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 address or phone
number is unavailable, place NIA in the blank )
Part A.
Project Name Providence Place
2. Location of land -disturbing activity County Cabarrus
City or Township Kannapolis
Highway/Street 2600 Shad Lane Latitude(decimai degrees) 35 45491 Longitude(deurna; degrees)-80.62534
3 Approximate date land -disturbing activity will commence: July 1 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Residential
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ 400 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example. 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ
7. Has an erosion and sediment control plan been filed? Yes � Enclosed C No
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity.
Name. utry Dawsey E-mail Address ad duet net
Phone: Office # (704) r13-1072 Mobile #
9 Landowner(s) of Record (attach accompanied page to list additional owners):
Providence Properties of the Carolinas, LLC (704) ?13-1072
Name Phone. Office # Mobile #
152C Candlew ck Court 1520 Candlewyck Court
Current Mailing Address Current Street Address
Kannapolis NC 28081 Kannapolis NC 28081
City State Zip City State Zip
10 Deed Book No. 272 Page No. 39 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Providence Properties of the Carolinas, LLC
Company Name
1520 Candlewyck Court
Current Mailing Address
ad dnet.net
E-mail Address
1520 Candlewyck Court
Current Street Address
NC 28081 Kannapolis NC 28081
City State Zip City State Zip
Phone: Office # (704) 7 3-1072 Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Ellis A Dawsey, Jr
ad dnet.net
Name of Registered Agent
E-mail Address
1520 Candlewyck Court
1520 Candlewyck Court
Current Mailing Address
Current Street Address
Kannapolis NC
28081 Kannapolis
NC 28081
City State
Zip City
State Zip
Phone: Office # 7 4 -1 7
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party
is not a resident of North Carolina,
give name and street address
of the designated North Carolina agent who is registered on the NC Secretary
of State business registry:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City
State Zip
Phone: Office #
_. Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name. attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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 individuals)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Ellis A Daw.5ey Jr
Type or print name
Signa ure
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Member
Title or Authority
7 22
Date
IjJ011wq a Notary Public of the County of 64:�"
State of North Carolina, hereby certify that .0 �- ,,appeared personally
before me this day and being duly sworn acknowledged that the above rm as executed by him/her.
Witness my hand and notarial seal, this-'-�9ay of 20 22
KIMBERLY M BUMGARDNER'
Notary Public, North Carolina Notar
Cabarr.us County
My commission Expires
May02, 2027 My commission expires 1)12m- 21 �OZ 7