NCC232649_FRO Submitted_20230901

044,&�1T��y
7 Mecklenburg County Soil Erosion and Sedimentation
" Control Ordinance
s . 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:
2. Address of land-disturbing activity:
.dam
3. Approximate date land-disturbing activity will commence: - / &-, .23
Month Day Year
4. Purpose of development(Residential, Commercial, Industrial, etc.): ZesArikij
5. Approximate acreage of land to be disturbed or uncovered: -_ __-0.384
6. Total site acreage: •_ _ -
7. Landowners of record (use blank pages
`tto`list additional owners as necessary):
Owner#1 Name: l f .) �.GYL-5_4_, inl' n
.0„?Q,..5_Address: lg../ 206011_Leda?) - lid/l'e- — —
- biur dit22 lVG,- 31P - .
Telephone: 704-Qt?7-79, O Fax:
Email Address: jam- i yes , (�
Owner#2 Name:
Address:
Telephone: Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
BookIN/0 3 Page i. 7f - Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 3-1-OR

Continue - Financial Responsibility/Ownership Form
PART B
I. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: _ 1~ ,..roiyijazi J' 1//A/f;5,, u-e'
Address: Pa .Th ' Ilik -
Telephone: 714./.- !l7 79.5e) Fax: JI//¢
Email Address: C1`ll[ Yjie. ' ao S < I�11_-_ - -
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax:
Email Address:
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.)
Aty/zvie, I Vie. LW NIRr7��
Printed Na a Tit
inay.6.6Le_Viliee.zze_s..._. /01/f4g...
Signature Date
1, iliSj-1 nornA/1 i e/lo , a Notary Public of the
County of 1'_I&IA(011 btr. , State of J 7_i Ca ro/I/ a. , hereby
certify that_IrVirjorie. "Pi e//c,_ personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, t is? !k'
" day of fnirtbe� , 20 _
Notary Signature: 464 i'>~ _Onan,Lf
My Commission expires: Sept _ 6 ��y ....--
ELISA ROMANIELLO
Notary Public, North Carolina
Mecklenburg County
Mecklenburg County Land Use and Environmental Services My Commission Expires
700 N.Tryon Street Suite 205 September 15,2024
Charlotte,NC 28202-2236
[phone]
FAX(7041 1+6-4391