NCC221715_FRO Submitted_20220505

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 Belle Mar
2. Location of land -disturbing activity: County Union City or Township Weddington
Highway/Street Old Mill Road Latitude 35.013918 Longitude-80.760952
3. Approximate date land -disturbing activity will commence: March 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 Acres
6. Amount of fee enclosed: $ $1,600 ($400/acre) 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 Kent Olson E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Belle Mar, LLC
Name Telephone
11121 Carmel Commons Blvd. #360 Same
Current Mailing Address Current Street Address
Charlotte NC 28226 Same
City
10. Deed Book No. 8226
Part B.
State
Fax Number
Zip City State Zip
Page No. 0043 Provide a copy of the most current deed.
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):
Development Solutions Group, LLC [e-mail]
Name
11121 Carmel Commons Blvd, STE 360
Current Mailing Address
Charlotte NC 28226
City State
Telephone [phone]
E-mail Address
Same
Current Street Address
Same
Zip City
Fax Number
State
Zip

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,
State
E-mail Address
Current Street Address
Zip City State Zip
Fax 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
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.
Ken . Ison
Ze
tint name
Managing Member
Title Cyr Auth ity
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Dat
I, A ra , a Notary Public of the County of /,, ll�]
State of North Carolina, hereby certify that i" -p- nt ow) appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand }d notaAgp'` � d of I 1 20 2 Z
UNION COUNTY, NC �7
My commissim rXpirm- - . fi l�1�J al. I l f' t�
Notary v
Seal
My commission expires