NCC216562_FRO Submitted_20211124

Financial Responsibility/Ownership Form Sedimentation Pollution Control Ordinance APR 2 G 2021
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 Parcel 1D Number
065 431
1. Project Name
Shay Crossing
2. Location of land -disturbing activity (Highway/Street)
Earnhardt Road
Latitude
Longitude
35d 38' 23.7" N 80d 26' 14.4"W
3. Approximate date land -disturbing activity will be commenced
3/1/2021
4. Purpose of development (residential, commercial, industrial, etc.)
Residential
S. Approximate acreage of land to be disturbed or uncovered
127.4
6. Person to contact should sediment control issues arise during land -disturbing Cell Phone Number
activity
704-288-7256
Andrew J. McDonald
Email Address
[e-mail]

7. Landowner of Record
Landowner of Record
Dependable Development, Inc.
Name
Current Mailing Address
2627 Brekonridge Centre Drive Monroe NC 28110
8. Recorded in Deed Book Number
Name
Current Mailing Address
Page Number
1334 697
Part B
1. Person or Firm who are financially responsible for this
land -disturbing activity
'true Homes, LLC
Name of Person(s) or Firm(s)
Current Mailing Address
2627 Brekonridge Centre Drive Monroe NC 28110
Phone Number
704-288-7256
Person or Firm who are financially responsible for this
land -disturbing activity
Name of Person(s) or Firm(s)
Current Mailing Address
Phone Number
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
Andrew J. McDonald Market Partner - Land Development
Signature Date
mm/dd/yvri
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1, _ IGC S. �ay(!!C , a Notary Public of the County of State of North Carolina,
hereby certify that Aa%gM,4 %�iC . DAJAppeared personally before me this da and being duly worn acknowledged
that the above form was executed by him/her. Witness my hand and seal of Notary, this day of , 20,)
Notary My commission expires
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mm/dd/yyyy
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Seal
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