NCC222411_FRO Submitted_20220705

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. Allburn Subdivision
1. Project Name
2.
3
Location of land -disturbing activity: CountyCabarruss
Highway/Street f_akeland Rd. Latitude
City or Township Harrisburg
Approximate date land -disturbing activity will commence:6.1.21
Longitude.
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 48.46
6. Amount of fee enclosed: $Already paid 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 Mike Tidwell E-mail Address [e-mail]
Telephone[phone] cell # 980-260-8868 Fax #
0
Landowner(s) of Record (attach accompanied page to list additional owners)
Taylor Morrison of the Carolinas 980-260-8868
Name Telephone Fax Number
11405 N Community House Rd. 11405 N Community House Rd.
Current Mailing Address
Charlotte NC
City State
10. Deed Book No.15171
Current Street Address
28277 Charlotte NC 28277
Zip City
Page No.0290
State
Zip
Provide a copy of the most current deed.
Part B.
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.
Taylor Morrison of the Carolinas [e-mail]
Name
11405 N Community House Rd.
Current Mailing Address
Charlotte NC
City State
Telephone [phone]
E-mail Address
11405 N Community House Rd.
Current Street Address
28277 Charlotte NC 28277
Zip City State Zip
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:
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 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.
Thomas Johnson
Type or print name
Signature
VP Land Development
Title or Authority
10/13/21
Date
a Notary Public of the County ofMucjcl AD") t"q
State of North Carolina, hereby certify that I YAI r)� appeared
personally before me this day and being
executed by him.
duly sworn acknowledged that the above form was
Witness my,,gvi#w4 s rial seal, this ! ,day of f , 20
rUL
or
Al?k e� � Notary
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My commission expires�J