NCC215746_FRO Submitted_20211101

Financial ResponsibilitylOwnership 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.
Part A
1. Project Name
Brightleaf Terrace
2. Location of land -disturbing activity (Highway/Street)
2354 Statesville Blvd; 2368 Statesville Blvd; 2386 Statesville Blvd; "0" Statesville Blvd.
Latitude Longitude
35.6985-80.5265
3. Approximate date land -disturbing activity will be commenced
� 6/1/2021
4. Purpose of development (residential, commercial, industrial, etc.)
Residential, Multi -Family
5. Approximate acreage of land to be disturbed or uncovered
7.23 acres
6. Person to contact should sediment control issues arise during land -disturbing
activity
Matt Raab
Parcel ID Number
329 039; 329 378; 329
379; 329 040; 329 279
Cell Phone Number
[phone]

Email Address
[e-mail]
7. Landowner of Record Landowner of Record
Brightleaf Terrace, LLC
Name Name
Current Mailing Address Current Mailing Address
P.Q. Box 787
Arnold, MD 21409
S. Recorded in Deed Book Number rage Number
1369 Pages: 170; 172; 174; 176
Part B
1. Person or Firm who are financially responsible for this Person or Firm who are financially responsible for this
land -disturbing activity land -disturbing activity
Brightleaf Terrace, LLC
Name of Person(s) or Firm(s) Name of Person(s) or Firm(s)
Current .Mailing Address Current Mailing Address
P.O. Box 787
IArnoid, MD 21409
Phone Number Phone Number
[phone]
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 Registered Agent
Current Mailing Address Current Street Address
Telephone Number Telephone 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 authority to execute instruments 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
Brightleaf Terrace, LLC by Kent Place Holdings, LLC its Member
Manager, by Stephen Brock
Signature
Date
mmlddlyyyy
q f 13/2-67-1
.......................................................................................................................................................................................
�O L �0 , a No ary P State of blic of the County of � q ]i�}i� � �� L,,
hereby certify tha appeared personally before me this day
eing dul sworn acknowled ed
that the above form was executed by himlber. Witness my hand and seal of Notary, this of 23(

Notary
IF
Sea' #Nk
ketktist
U Ml d a copy of the Erosion and Sedimentation
CoWwl 'Pklh Checklist (PDF)
My commission expires
mmldd/yyyy E
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