NCC242244_FRO Submitted_20240729

Rowan County
Financial Responsibility/Ownership Form Sedimentation Pollution Control Ordinance
No person may initiate any land-disturbing activity on one or more acres as covered by the ordinance before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Rowan County Environmental Management Department.
Parcel ID Number
Lot 56: 326H039
Lot 185: 326N001
1. Project Name*
Crescent Golf(Lots 56& 185)
2. Location of land-disturbing activity(Highway/Street)*
Lot 56: 406 Doral Court
Lot 185: 209 Hogans Valley Way
3. Latitude Longitude
Lot 56: 35.704086 Lot 56: -80.488975
Lot 185: 35.696939 Lot 185: -80.487844
4. Approximate date land-disturbing activity will be commenced
06/07/2024
5. Purpose of development(residential, commercial, industrial, etc.)
Residential Homebuilding
6. Approximate acreage of land to be disturbed or uncovered*
1.96 Acres
,
*this information will be made available on the Rowan County Planning&Development website.
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7. Person to contact should sediment control issues arise during land-disturbing Cell Phone Number*
activities*
Henry Kirchner 704-754-5460
Email Address
[e-mail]
8. Landowner of Record Landowner of Record
Century Communities Southeast, LLC
Name Name
Current Mailing Address Current Mailing Address
7401 Carmel Executive Park Drive
Charlotte, NC 28226
9. Recorded in Deed Book Number Page Number
Lot 56: 792 Lot 56: 785
Lot 185: 786 Lot 185: 374
Part B
1 Person or Firm who are financially responsible for Person or Firm who are financially responsible for this
this land-disturbing activity land-disturbing activity
Century Communities Southeast, LLC
Name of Person(s)or Firm(s) Name of Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
7401 Carmel Executive Park Drive
Charlotte, NC 28226
Phone Number Phone Number
704-754-5460
*this information will be made available on the Rowan County Planning&Development website;
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Rowan County
a. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of a North
Carolina Agent.
Name of Agent Name of Agent
Current Mailing Address Current Mailing Address
Phone Number Phone 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 the name and street address of the Registered Agent.
Name of Agent Name of Agent
National Registered Agents, Inc.
Current Mailing Address Current Mailing Address
•
160 Mine Lake Ct. Ste. 200
Raleigh, NC 27615
Phone Number Phone Number
•
*this information will be made available on the Rowan County Planning&Development website.
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Rowan County
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 authority to execute instrument s for the
Financially Responsible Person). I agree to provide correctional information should there be any change in the
information provided herein.
Name Title or Authority
Andrew Rouzer Division President
Signature Date
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I, ))26 , a Notary Public of the County of 1 ' `e'(
State of North Carolina, hereby certify that Qn(cCl'1 �iJ,�2 (L- appeared personally before me this
day and being duly sworn acknowledged that the above form was executed by him/her. Witness my hand and seal of
Notary, this day of '3Jr\.10._ , 20 .
Notary My commission expires
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Date
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� Notary Public
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County
My Comm. Exp.
0 12-15-2024
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Checklist
Download a copy of the Erosion and Sedimentation
Control Plan Checklist(PDF)
*this information will be made available on the Rowan County Planning&Development website.
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