NCC231568_FRO Submitted_20230606

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project NameStadium Lofts (Block 4A and 4B)
`If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Cabarrus City or Township Kannapolis
West Avenue 35.49819 80.62589
Highway/Street Latltude(decimallegrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence:January 15, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
Residential/Commercial
2xnc0—c.v...
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
6. Amount of fee enclosed: $1 00 . The application fee of$100.00 per acre (rounded
up to the next acre)is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Peter Flotz E-mail [e-mail]
Phone: Office# [phone] Mobile# (321 )-302-2930
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Right Field Development, LLC (954)-332-1140 x 141140
Name Phone: Office# Mobile#
c/a Lansing Melbourne Group 101 NE 3rd Avenue Suite 1500 do Lansing Melbourne Group 101 NE 3rd Avenue Suite 1500
Current Mailing Address Current Street Address
Ft Lauderdale FL 33301 Ft Lauderdale FL 33301
City State Zip City State Zip
Page No.0017
10. Deed Book No. 16255 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Right Field Development, LLC [e-mail]
Company Name E-mail Address
Go Lansing Melbourne Group 101 NE 3rd Avenue Suite 1500 c/o Lansing Melbourne Group 101 NE 3rd Avenue Suite 1500
Current Mailing Address Current Street Address
Ft Lauderdale FL 33301 Ft Lauderdale FL 33301
City State Zip City State Zip
Phone: Office# [phone] Mobile# N/A
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry,give name and street address of the Registered Agent:
Peter Flotz [e-mail]
Name of Registered Agent E-mail Address
115 West Avenue 115 West Avenue
Current Mailing Address Current Street Address
Kannapolis NC 28081 Kannapolis NC 28081
City State Zip City State Zip
Phone: Office# [phone] Mobile# [phone]
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c)If the Financially Responsible Party is engaging in business under an assumed name,give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership,or other company not registered and doing business under an assumed name,attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Peter Flotz Managing Member
T,,' y
e • int name Title or Authority
2 - 5/1/23
; Date
I Diane Siuzda , a Notary Public of the County of Broward
Florida Peter Flotz
State of North Cafelina, 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 notarial seal, this 1 day of May 20 23
1 DIANE SItIIDAK I Nota y
Notary Put State of fbrlda I Notary 7!_. � Sec' mmluion N NM 355521
I ' My Comm.rapl►es Mar 24,2027 ( 3/24/27
( """Bonded through National notary Assn. I My commission expires

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
KB4, LLC (321)-302-2930
Name Phone: Office# Mobile#
1290 W Eau Gallie Blvd 101 NE 3rd Ave, Ste. 1500
Current Mailing Address Current Street Address
Ft Lauderdale FL 33301 Ft Lauderdale FL 33301
City State Zip City State Zip
Deed Book No. 15855 Page No.0125 Provide a copy of the most current deed.
Landowner 3 of Record:
Right Field Development, LLC [phone]
Name Phone: Office# Mobile#
do Lansing Melbourne Group 101 NE 3rd Avenue Suite 1500 do Lansing Melbourne Group 101 NE 3rd Avenue Suite 1500
Current Mailing Address Current Street Address
Ft Lauderdale FL 33301 Ft Lauderdale FL 33301
City State Zip City State Zip
Deed Book No. 16404 Page No.0101 Provide a copy of the most current deed.
Landowner 4 of Record:
•
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.