NCC243605_FRO Submitted_20241120

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. Zaxby's
1. Project Name
2. Location of land-disturbing activity: CountyCabarruS City or Township Kannapolis
Highway/Street North Cannon Boulevard Latitude 35.500836 Longitude-80'609788
3. Approximate date land-disturbing activity will commence:08/05/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 '1 1
6. Amount of fee enclosed: $ 200'00 . 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? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Michael Moore E-mail Address [e-mail]
Telephone Cell# 832-434-6421 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Kannapolis 704-920-4444
Name Telephone Fax Number
401 Laureate Way 4010 Laureate Way
Current Mailing Address Current Street Address
Kannapolis, NC 28081 Kannapolis, NC 28081
City State Zip City State Zip
10. Deed Book No. 12670 Page No.266 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.
Zaxby's Properties LLC [e-mail]
Name E-mail Address
2002 Summit Boulevard NE, 12th Floor 2002 Summit Boulevard NE, 12th Floor
Current Mailing Address Current Street Address
Atlanta, GA 30619 Atlanta, GA 30619
City State Zip City State Zip
Telephone [phone] Fax Number

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 [e-mail]
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
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax 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-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.
Robert Colvin Vice President, Controller
Type o print pme Title or Authority(t
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Sature ' Date
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I, Ke,\/'‘N / 1a5Ve.,r'S , a Notary Public of the County of OGcarte,e_,
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State of Perth-C—afel+ea; hereby certify that ?o9 '\- Lolv►v\ appeared
personally before me this day and being duly sworn acknowledged that the above form was
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Wit �rr�► •• nal seal, this day of !t ti. SST , 20 �•�
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