NCC216277_FRO Submitted_20211110

FINANCIAL. RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A. River Point Phase 4C
1, Project Name
2, Location of land -disturbing activity: County Cabarrus City or Township Kannapolls
Highway/Street Shiloh Church Road Latitude 35."I' 4554026543 Longitude - 80.77080143�n5�5
3. Approximate date land -disturbing activity will commence: November 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 5.1
6. Amount of fee enclosed: $ paid . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a coiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mr. Timothy Arey E-mail Address [e-mail]
Telephone [phone] cell # 704-305-2999 Fax #
PC
Landowner(s) of Record (attach accompanied page to list additional owners):
Spire Davidson, LLC 704-930-7526
Name Telephone
227 W. 4th St 227 W. 4th St
704-930-7526
Fax Number
Current Mailing Address Current Street Address
Charlotte, NC 28202 Charlotte, NC 28202
City State Zip City State Zip
10, Deed Book No. 13202 Page No. 0295-0299 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.
Farm P4 Partners LLC [e-mail]
Name E-mail Address
1401 E. 7th Street, Suite 200 1401 E. 7th Street, Suite 200
Current Mailing Address Current Street Address
Charlotte, NC 28204 Charlotte, NC 28204
City State
Telephone [phone]
Zip City State Zip
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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: p
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Name of Registered Agent E-mail Address
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Current Mailing Address
(k Ay ("Ap- Aj
City State Zip
Telephone oy 7?2 G goo
76 S�e�- �SfL Zoo
Current Street Address
('kGvro�k AI[ Z6ZoL(
City
Fax Number
State Zip
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.
►��—�,�� ���y M4^/A���
Type or print name
Signature
Title or Authority
�
Date
a Notary Public of the County of�5
State of North Carolina, hereby certify that I I �)10+k `i � Ry� appeared
personally before me this day and being duly sworn acknowledged thdt the above form was
executed by him.
Witness my hand and notarial seal, this I day of 6 , 20 2 f
BRANDY L GOLTZ
NOTARY PUBLIC U�4
CABARRUSCOUNTY,,NO N tary
MY G0MMI ION EXPIRES;
RQ:alMy commission expires Cj. a_