NCC217184_FRO Submitted_20220103

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 Environment and Natural Resources. (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 Oaktree Apartments & Townhomes
2. Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street6647 Rumple Rd. Latitude 35.298320 Longitude 80.789900
3. Approximate date land -disturbing activity will commence: 1/10/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4 . 4
6. Amount of fee enclosed: $ $325. 00 . 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 Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Yates Warwick E-mail Address Yates@keareyconstruction . com
Telephone [phone] Cell # 704-903-8733 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Oaktree Apartments & Townhomes, LLC 704-577-4138
Name
Current Mailing Address
City
State Zip
Telephone Fax Number
8928 Kentucky Derby Dr
Current Street Address
Waxhaw NC 28173
City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Kearey Builders, Inc. [e-mail]
Name E-mail Address
2915 Charlotte Highway
Current Mailing Address Current Street Address
Mooresville NC 28117
City State Zip City State Zip
Telephone [phone] Fax Number 980-444-6540

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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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.
Ryan Kearey
or print name
Vice President
Title or Authority
12/29/2021
Date
I, �,h��% l �%, N rYti� , a Notary Public of the County of .at4)
State of North Carolina, hereby certify that ' appeared
personally before me this day and being duly sworn acknowledge that the above form was
executed by him.
Witness my hand and notarial seal, this .1-Iday of7 , 20 9
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