NCC242437_FRO Submitted_20240812

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on more thanl.0 acres as covered by the Act before this form and
an acceptable erosion and sedimentation control plan have been completed and approved by the Town of
Weddington. Submit this form to: 1924 Weddington Road, Weddington, NC 28104. (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.
1. Project Name Luna Subdivision
2. Location of land-disturbing activity: County Union City or Township Weddington
Highway/Street 5932 Weddington-Matthews RdLatitude 35.031056 Longitude -80.745577
3. Approximate date land-disturbing activity will commence: June 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 27 acres
6. Amount of fee enclosed: $ 10,800 . The application fee of$400 per acre (rounded up to the next
acre)is assessed without a ceiling amount(Example: a 10-acre application fee is$4,000).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Robert Price E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners): see additional sheet
Toll Southeast LP Company Inc. [phone]
Name Telephone Fax Number
9130 Kings Parade Blvd
Current Mailing Address Current Street Address
Charlotte,NC 28273
City State Zip City State Zip
10. Deed Book No. 8879 Page No. 0095 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.
Toll Southeast LP Company, Inc.-Robert Price [e-mail]
Name E-mail Address
9130 Kings Parade Blvd
Current Mailing Address Current Street Address
Charlotte NC 28273
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 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 chap in the information provided herein../
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Sign ure Date
I, /'7► �tr on , a Notary Public of the County of CThafAv
State of North Carolina, hereby certify that .(2o`oe(-s- f,(' �' .e, appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by
him.
Witness my hand and notarial seal, this L.%ST day of V\c-3--.k , 20 214
ANli GIo
^1; ,;,�Notary Public, North
Carolina
Gaston County Notary
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