NCC231713_FRO Submitted_20230605

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 Parcel ID Number
109-149, 133-165
1.Project Name*
Ryder Place
2.Location of land-disturbing activity(Highway/Street)"
E. Ryder Ave.and N. Upright St.
Latitude Longitude
35.542387 -80.603121
3.Approximate date land-disturbing activity will be commenced
6/1/2023
4.Purpose of development(residential,commercial,industrial,etc.)
Residential
�.Approximate acreage of land to be disturbed or uncovered*
12.90 Ac.
6.Person to contact should sediment control issues arise during land-disturbing Cell Phone Number*
activity"
704-787-5622
David Hughes
`this Information will be made available on the Rowan County Planning&Development website.
Email Address
[e-mail]

7.Landowner of Record Landowner of Record
Villas at Landis Development, LLC.
Name Name
Current Mailing Address Current Mailing Address
P.O. Box 3965,Mooresville, NC 28117
8.Recorded in Deed Book Number Page Number
1417 956&957
Part B
1.Person or Firm who are financially responsible for this Person or Firm who are financially responsible for this land-
land-disturbing activity disturbing activity
Villas at Landis Development, LLC.
Name of Person(s)or Firm(s) Name of Person(s)or Firm(s)
Current Mailing Address Current Mailing Address
P.O.Box 3965, Mooresville, NC 28117
Phone Number Phone Number
704-787-5622
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

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
David Hughes
Current Mailing Address Current Street Address
P.O. Box 3965, Mooresville, NC 28117 236 Raceway Drive, Mooresville, NC 28117
Telephone Number Telephone Number
704-787-5622
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 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
David Hughesaet
Signature Date
•
i, 1i"1"h— P•'""` ` Notary`Public of the County of -e C'if[v2t)oL,1'- State of North Carolina,
hereby certify that )Oi3t(3( {--V0riS20.Sappeared personally before me this day and being duly sworn acknowled&ed
that the above form was executed by him/her.Witness my hand and seal of Notary,this c3 day of ,2j
Notary My commission expires
rnmid d(yyyy EMMA BOWLES
Notary Public, North Carolina
j/zrL_ l Mecklenburg County
My Commission Expires
March 29,2028
Seal
Checklist
Download a copy of the Erosion and Sedimentation
Control Plan Checklist(PDF)