NCC242612_FRO Submitted_20240828

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Cleveland Hill
1. Project Name
2. Location of land-disturbing activity: County Cleveland City or Township Shelby
Highway/Street Eaves Road Latitude 32.264101 Longitude-81.530729
3. Approximate date land-disturbing activity will commence:9/1/2024
4. Purpose of development(residential,commercial, industrial, institutional,etc.):Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):53
6. Amount of fee enclosed: $ 0 . The application fee of$100.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example:8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mark Henninger E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Lennar Carolinas, LLC 704-759-6000
Name Telephone Fax Number
6701 Carmel Road Suite 425 6701 Carmel Road Suite 425
Current Mailing Address Current Street Address
Charlotte, NC 28226 Charlotte, NC 28226
City State Zip City State Zip
10. Deed Book No. 1264 Page No.800 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.
Lennar Carolinas, LLC
Name E-mail Address
6701 Carmel Road, Suite 425 6701 Carmel Road, Suite 425
Current Mailing Address Current Street Address
Charlotte, NC 28226 Charlotte, NC 28226
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:
Corporate Creations Inc.
Name E-mail Address
15720 Brixham Hill Avenue #300
Current Mailing Address Current Street Address
Charlotte, NC 28227
City State Zip City State Zip
Telephone [phone] 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:
Lennar Carolinas, LLC
Name of Registered Agent E-mail Address
6701 Carmel Road Suite 425 6701 Carmel Road Suite 425
Current Mailing Address Current Street Address
Charlotte, NC 28226 Charlotte, NC 28226
City State Zip City State Zip
Telephone [phone] 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 change in the information provided herein.
Mark Henninger Division President
Type or print a Title or Authority
Signature Date .
I, }'A-T1Z.l,C-1#- 14-14-rr10San , a Notary Public of the County of Ont OVA
State of North Carolina, hereby certify that MA7 k- 14-4.['t.Vt[,K _appeared
personally before me this day and being duly sworn acknowled ed that the above form was
executed by him.
Witness my hand and notarial seal, this day of iAn�cj IT _, 20 02-4_1
(4,444,-----
N J ary
Seal
PATRICIA HAMPSON My commission expiresj2-/ 0 1-142S-
Notary Public, North Carolina
Union County
My Commission Expires
December 07,2025
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