NCC242809_FRO Submitted_20240912

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.
1. Project Name Home2 Lakepointe
2. Location of land-disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street Cascade Pointe Blvd Latitude35.196 Longitude -80.914
3. Approximate date land-disturbing activity will commence: 10/15/24
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):5
325.00
6. Amount of fee enclosed: $ — The application fee of$65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes_ No,X _ Enclosed__
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Charles DeBord [e-mail]
Name E-mail Address
Telephone_704-357-6095 Cell# 704-326-6215 Fax# [phone],
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Lakepointe Hotel Investments, LLC_ 704-345-5562
Name Telephone Fax Number
6025 Blakeney Park Drive, Suite 125_ 2215 Cascade Pointe Blvd.,
Current Mailing Address Current Street Address
Charlotte NC 28277 Charlotte NC 28208
City State Zip City State Zip
10. Deed Book No. 31601 __Page No. 948 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.
Lakepointe Hotel Investments.LLC [e-mail]
Name E-mail Address
64ma1akeney Park jady_e,..suiieJ25 2215 Cascade Pointe Blvd.,
Current Mailing Address Current Street Address
Charlotte NC 28277 Charlotte NC 28208
City State Zip City State Zip

Telephone_704.345.5562 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:
Chandresh Patel [e-mail]
Name of Registered Agent E-mail Address
6025 Blakpnpy Park Drive, Suite 125_
Current Mailing Address Current Street Address
Charlotte NC 28277
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.
Chandresh Patel Managing Member
Type or rint name Title or Authority
. , 16--jaa_
Signature Date
I, T -an.cL' g.• ?e.()C4 LO?A , a Notary Public of the County of
State of North Carolina, hereby certify that C incvi cc€-S11 Pc± -I appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand si q rial seal, this.5 day of_SePIe b r°.r , 20 2y_
� 0. 4gE
� _��anc� k3• I e..rnu.lort�
", W CanNn.Expo V' Notary
3 al? -2 -,
/ .+/2o2ç2413 , •�tja My commission expires_
0'
,•,,eURG CO',