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HomeMy WebLinkAboutNCC220277_FRO Submitted_20220113NOUR Mecklenburg County Soil Erosion and E ' Sedimentation Control Ordinance ° GA Financial Responsibility/Ownership Form No person shall initiate any land -disturbing activity covered by Section 6 of the Mecklenburg County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to completing and filing this form with Mecklenburg County Land Use and Environmental Services. The financially responsible party will be on record as the party to accept any Notices of Violation or related documents for any non-compliance with the above Ordinances. if the financially responsible party is out of State, a North Carolina agent must be assigned. Please Type or Print PART A 1. Project where land -disturbing activity is to be undertaken: IPEX New Production Buildi 2. Address of land -disturbing activity: 10320 Rodney Street, Pineville, NC 28134 3. Approximate date land -disturbing activity will commence: November 01 2021 Month Day Year 4. Purpose of development (Residential, Commercial, Industrial, etc.): Industrial/Manufacturing 5. Approximate acreage of land to be disturbed or uncovered: 9.1 acres 6. Total site acreage: +/- 7.9 acres 7. Landowners of record (use blank pages to list additional owners as necessary): Owner #1 Name: Pierre Coulombe Address: 3 Place du Commerce, bureau 101, Ile des Soeurs, Verdun, QC H3E 1 H7 Canada Telephone: (514) 769-3445 A 20308 Fax: Email Address: pierre.coulombe@ipexna.com Owner #2 Name: Martin Robitaille Address: 3 Place du Commerce, bureau 101, Ile des Soeurs, Verdun, QC H3E 1 H7 Canada Telephone: 514-769-3445 A 20336 Fax: Email Address: martin.robitaille@ipexna.com 8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list additional deeds or instruments as necessary): Book 11200 Page 527 Book Page Book Page Book Page (continue on back or separate pages as necessary) Form Revised 12-2016 Continue - Financial Responsibility/Ownership Form PART S 1. Person(s) or firm(s) financially responsible for this land -disturbing activity_ Person or Firm: Pierre Coulombe Address: 3 Place du Commerce, bureau 101, lie des Soeurs, Verdun, QC H3E 1 H7 Canada Telephone: 514 7E9-3445 xt. 20308 Fax: Email Address: pierre.coulombeC&ipexna.com 2. North Carolina agent for the person or firth who is financially responsible: Person or Firm: IPEx USA, I_LC - Shawn White Address: 10100 Rodney Street, Pineville, NC 28134 Telephone: (704) 889-2431 Xt. 50209 Fax: Email Address: shawn.white(�iexam_e_rica.com 3. The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath. (This form must be signed by the financially responsible person if an individual or by an officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for the financially responsible company or entity, if not an individual.) Pierre Coulombs VP VP of Engineering Printed N. UU�s Title siggature v •' y ''x• Date �a , a Notary Public of the County of ^�r►��rl�a State of C�c , hereby u certify that Ong A cl kze personally appeared before me this day and under oath acknowledged that this form was executed by him/her. Witness my hand and notarial seal, this Notary Signature: _— +.. My Commission expires: day of C-N -sc, YeA Mecklenburg County Land Use and Environmental Services Agency 2145 5uttle Ave. Charlotte, NC 28208-5237 Phone (980) 314-3234