NCC240257_FRO Submitted_20240130

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.1. Project Name Hathaway at Lake Norman
2. Location of land-disturbing activity: County Catawba City or Township Denver
Highway/Street E NC Hwy 150 Latitude 35.5640 Longitude-81 .0580
3. Approximate date land-disturbing activity will commence:02/04/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Multifamily residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):25 acres
6. Amount of fee enclosed: $ 2500 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed
Ii 8. Person to contact should erosion and sediment control issues arise duringland-disturbingactivity:
Y
Name
David Gerdeman E-mail Address [e-mail]
Telephone[phone] Cell# [phone] Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Hathaway at Lake Norman, LLC [phone] N/A
Name Telephone Fax Number
14300 Ridge Rd 14300 Ridge Rd
Current Mailing Address Current Street Address
North Royalton, OH 44133 North Royalton, OH 44133
City State Zip City State Zip
10. Deed Book No.03852 Page No.0173 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.
Hathaway at Lake Norman, LLC [e-mail]
Name E-mail Address
14300 Ridge Rd 14300 Ridge Rd
Current Mailing Address Current Street Address
North Royalton, OH 44133 North Royalton, OH 44133
City State Zip City State Zip
Telephone[phone] Fax Number N/A

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:
CT Corporation System N/A
Name E-mail Address
160 Mine Lake Ct, Ste 200 160 Mine Lake Ct, Ste 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Raleigh, NC 27615
City State Zip City State Zip
Telephone[phone] Fax Number N/A
(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:
Aaron Gross [e-mail]
Name of Registered Agent E-mail Address
14300 Ridge Rd
Current Mailing Address Current Street Address
North Royalton, OH 44133
City State Zip City State Zip
Telephone[phone] Fax Number N/A
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.
Aaron Gross Vice President- Hathaway at Lake Norman, LLC
Type or pr. name Title or Authority
1/26/2024
Signature Date
I, 1\ilZLU'tCI'1 PJ\Z( a Notary Public of the County of h(YI&- )
t�r'ie Aaron Gross
State of , hereby certify that appeared
personally before me this day and being duly sworn acknowledged hat the above form was
executed by him. ff / I.'��
Witness my hand and notarial seal, this �nday of ` Vu LULL , 20 2
C, WillarOmligq•
O ,IALS `���� MAUREEN MANTE
ttom Public,State of Ohio Notary �J /,� "� /•�7
*= 1V1� Commission Expires l/ C�V� LJI�v
2612024 My commission expires I i
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