NCC221108_FRO Submitted_20220318

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 Pleasant Grove Road Apartments
2. Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street6242 Pleasant Grove Rd. Latitude 35.304 Longitude-80.902
3. Approximate date land -disturbing activity will commence: 3/21/22
4. Purpose of development (residential, commercial, industrial, institutional, etc): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.57
6. Amount of fee enclosed: $ 650.00 . 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 x No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Justin Roath E-mail Address iustin(c-)keareyconstruction.com
Telephone [phone] Cell # 704-450-2003 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rama Yada 704-287-6252
Name Telephone Fax Number
8021 Wicklow Hall Dr
Current Mailing Address Current Street Address
Matthews NC 28104
City State Zip City State Zip
10. Deed Book No. B35788 Page No. 991 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.
Name
2915 Charlotte Hwy
Current Mailing Address
Mooresville NC 28117
City State Zip
iustina-keareyconstruction.com
E-mail Address
Current Street Address
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
E-mail Address
Current Street Address
State Zip City
Telephone 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.
Typft or print nam
Signatu
Vice President
Title or Authority
3/2/2022
Date
I, ' Cynthia Vincent , a Notary Public of the County of
Iredell
State of North Carolina, hereby certify that Justin Roath appeared personally before
me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 2nd
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My commission expires
4/1 /2022