NCC220177_FRO Submitted_20220110

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 Rainbow Drive Townhomes
2. Location of land -disturbing activity: County Cabarrus City or Township Kannapolis
Highway/Street 1460 Rainbow Drive Latitude 35.493694 Longitude-80.648201
3. Approximate date land -disturbing activity will commence: -January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.95
6. Amount of fee enclosed: $ 1,400_ N- " = _ = The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
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 Charles Kieler E-mail Address ckieler cDcardinaldevgrp.com
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Danny G. Bost. LLC
Name Telephone Fax Number
783 Williamsburg Dr NE
Current Mailing Address Current Street Address
Concord NC 28025
City State Zip City State Zip
10. Deed Book No. 5906 Page No. 0191 Provide a copy of the most current deed.
Part B.
5881 0022
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.
Westbrook Kannapolis LLC [e-mail]
Name E-mail Address
8320 Judy Witt Lane 8320 Judy Witt Lane
Current Mailing Address Current Street Address
Vienna VA 22182 Vienna VA 22182
City State Zip City State Zip

Telephone [phone]
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:
Costner Law Office, PLLC
Name
10125 Berkeley Place Drive
Current Mailing Address
[e-mail]
E-mail Address
10125 Berkeley Place Drive
Current Street Address
Charlotte NC 28262 Charlotte
City State Zip
Telephone [phone]
City
Fax Number 866-740-3542
NC 28262
State Zip
(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:
Costner Law Office, PLLC
Name of Registered Agent
10125 Berkeley Place Drive
Current Mailing Address
Charlotte NC 28262
City
State Zip
Telephone [phone]
[e-mail]
E-mail Address
10125 Berkeley Place Drive
Current Street Address
Charlotte
City
Fax Number 866-740-3542
NC 28262
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.
Charles J. Kieler
Type or print name
Signature
Member and Manager
Title or Authority
Date '
I, 1� ��� `l CJ, , a Notary Public of the County of ct `'(
State of North Carolina, hereby certify that dckd& �a e ��� appeared
personally before me this day and being duly sworn acknowiedged that the above form was executed
by him.
Witness my hand and notarial seal, this day of -e«o, 6 e F , 202— (_
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