NCC223624_FRO Submitted_20221021

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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 NIA in the blank.)
Part A. Nedgecliff Towns
1. Project Blame
2.
Location of land -disturbing activity: County Cabarrus
City or Township Kan napolis
Highway/Street S Ridge Ave Latitude 35.456 Longitude-80.616
3. Approximate date land -disturbing activity will commence: January 1, 2022
4
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 21 "04
6. Amount of fee enclosed: $ 1,365.00 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brian Johnson E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Breakwater Development LLC
Name
P4 Box 5144
Current Mailing Address
Mooresville, NC 28117
City
State Zip
Telephone Fax Number
862 Brawley School Rd, Ste 203
Current Street Address
Mooresville, NC 28117
City
State
Zip
10. Deed Book No. 15092 Page No. 342 Provide a copy of the most current deed.
Part B.
I. 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.
Mattamy Carolina Corporation [e-mail]
Name
2127 Ayrsley Town Blvd, Ste 202
Current Mailing Address
Charlotte, NC 28273
City
E-mail Address
Same as Mailing Address
Current Street Address
State Zip City
Telephone [phone]
Fax Number
State

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone— 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. It the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Brian Johnson [e-mail]
Name of Registered Agent E-mail Address
2127 Ayrsley Town Blvd, Ste 202 Same as Mailing Address
Current Bailing Address Current Street Address
Charlotte, NC 28273
City State Zip City
Telephone [phone] 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.
Brian Johnson
Type or name Title or Authority
Signature Date
(,t6an A �A a Notary Public of the County of or
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State of Carolina, hereby certi that ��" � �� � ,
personally before me this day and being duly sworn acknowledged that the above form was
executed by hire.
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