NCC233433_FRO Submitted_20231117

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may Initiate any land-di siurbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been co mpleted and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (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.
Heiliage Subdivision Phases 11-14(Lots 98-108,116-123,129-137,1434160,166-166,174-179,191-106.203-207)
1. Project Name
2. Location of land-disturbing activity: County Union City or Township Indian Trail/Wesley Chapel
Highway/Street Old Evergreen Pkwy. Latitude,36.034946 Longitude-80.677767
3. Approximate date land-disturbing activity will commence:08/2023
4. Purpose of development(residential,commercial,industrial,institutional,etc.):Residential SF
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):l� '27
6. Amount of fee enclosed:$' 130Q6'° . The application fee of$Litterl per acre (rounded
up to the next acre)is assessed without a ceiling amount (Example:a 9-acre application fee is$586).
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
James Losee E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
VK Heritages LLC
Name Teleph one Fax Number
1402E Riveredge Drive 175
Current Mailing Address Current Street Address
Tampa FL 33637
City State Zip City State Zip
10. Deed Book No.Below Page No.Below Provide a copy of the most current deed.
DEEM REFERENCES:ea 5767 PG 149,Da 5767 PG 137,man PG 717,DO 5801 PG 703
Part R.
1. Person(s) or firm(s) who are fine ncially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Eastwood Construction Partners, LLC
Name Email Address
2857 Westport Road
Current Mailing Address Current Street Address
Charlotte NC 28208
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) lithe Financially Responsible Party is a Pa rtnership 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:
im �-, k . s- M 6-, 44VP, e' �w vv�by s, 1-01
Name of Registered Agent E-mail Address
.P K5-2 V,OSA- 1004' LI
Current Mailing AddressCurrent Street Address
pL v a
City State Zip City State Zip
Telephone 7 Co'--S 3 IR`43 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 b e 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 F inancially Responsible Person). I agree to provide
corrected information should there be any change In the Information provided herein.
Marc Battiste VP of construction
Type or print name Title or Authority
14404.A..006 ZOZ-3
Signature Date
ArAI, \ 1f. lei a Notary Public of the County of �t\e1,Go hei
State of North arolina, hereby certify that appeared
personally before me this day and being duly sworn ac knowledged that the above form was
executed by him.
Witness my hand end notarial seal, this q1 'day of , 20
Not
F.
; Seal 74,
S. !
4b t1C., 0r commiss on expires ,