NCC222759_FRO Submitted_20220802

7/9/22, 10:48 AM
Rowan County
Financial Responsibility/Ownership Form Sedimentation Pollution Control Ordinance
No person may initiate any land -disturbing activity on one or more acres as covered by the ordinance before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Rowan County
Environmental Management Department.
Part A
1. Project Name
Hidden Hollow Subdivision - EC22.023
2. Location of land -disturbing activity (Highway/Street)
Centenary Church Rd
Latitude Longitude
35.632-80.762
3. Approximate date land -disturbing activity will be commenced
j 6/28/2022
4. Purpose of development (residential, commercial, industrial, etc.)
residential
5. Approximate acreage of land to be disturbed or uncovered
16.1
Parcel ID Number
572AO01-572AO20
6. Person to contact should sediment control issues arise during land -disturbing Cell Phone Number
activity 704-517-9108
Frank Kemo
Email Address
[e-mail]
https://www.rowancountync.gov/FormCenter/Print?formID=96&Preview=YES&Save=False&saved Progress ID= 1/3

7/9122, 10:48 AM
Rowan County
7. Landowner of Record
Brown Cobble Hollow Development, LLC
Name
Current Mailing Address
PO BOX 3965
Mooresville, NO 28117
Landowner of Record
Name
Current Mailing Address
8. Recorded hi Deed Book Number Page Number
1395 369
Part B
1. Person or Firm who are financially responsible for this
land -disturbing activity
Helmsman Homes, LLC
Name of Person(s) or Firm(s)
Current Mailing Address
116 Gasoline Alley, Suite 105
Mooresville, NO 28117
Person or Firm who are financially responsible for this
land -disturbing activity
Name of Person(s) or Firm(s)
Current Mailing Address
Phone Number Phone Number
9805001251
a. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of a North Carolina
Agent.
Name of Agent Name of Agent
Current Mailing Address Current Mailing Address
Phone Number Phone Number
https://www.rowancountync.goviFormCenter/Print?formlD=96&Preview=YES&Save=False&savedProgresslD= 2/3

7/9122, 10:48 AM
Rowan County
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 the name and street
address of the Registered Agent.
Name of Registered Agent
Current Mailing Address Current Street Address
Telephone Number Telephone 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 -hi -fact or if not an individual by
an officer, director, partner, or registered agent with authority to execute instruments for the Financially Responsible Person).
I agree to provide correctional information should there be any change in the information provided herein.
Name Title or Authority
Todd Farlow Lej(,Ll Cour t/
Signatw•e / Date
I- -
mm/dd/yyyy
i�i Z�Zb2 Z-
.......... ........................................
�.........................................................................................................
%1............................
S D�otary Public of the County of (�� C J �� State oi'North Carolina,
hereby certify that appeared personally before me this day and being duly sworn acknowledged
that the above form was executed by him/her. Witness my hand and seal of Notary, this � day of _Ict I. 20 e .z-
Notary My commission expires
n I mm/dd/yyyy J
Lf a u o
l/
Seal
Checklist
Download a copy of the Erosion and Sedimentation
Control Plan Checklist (PQQ
https://www.rowancountync.gov/FormCenter/Print?formID=96&Preview=YES&Save=False&savedProgressID= 3/3