NCC233349_FRO Submitted_20231109

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM cm-}n"'of• e
Soil Erosion and Sedimentation Control Ordinance NORTH C A R O L.INA
Instructions: No person shall initiate any land-disturbing activity on one or more acres,as covered in the Town of
Huntersville Soil Erosion and Sedimentation Control Ordinance,before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Huntersville. The Financially
Responsible Party will be on record as the party to accept any Notices of Violation or related documents for any non-
compliance of the Town of Huntersville Soil Erosion and Sedimentation Control Ordinance. If the Financially
Responsible Party resides out of state,a North Carolina agent must be assigned. All items on this form must be
filled out accurately and completely.
PART A- PROJECT AND LANDOWNER INFORMATION
1. Project name 77 Beltway - CATS Extension
2. Address of land-disturbing activity (number, street) 1110 Hambright Road, Huntersille, NC
3. Approximate date land-disturbing activity will begin 11/13/2023
4. Purpose of development (Commercial, Residential,
Industrial
Industrial, etc.)
5. Total acreage of land to be disturbed or uncovered 3 acres
6. Total site acreage 20.324 acres
7. Landowner(s)of Record. The names listed below must match the Deed(s).Attach a list of additional owners, if
applicable.
Note: If the landowner of record is not the person(s)firm(s),or Company's Financially Responsible Party,
as listed in Part B, item 1, a separate Letter of Consent, signed and dated by the Landowner of
Record,or their Authorized A:en t,is rc a uired.
Landowner 1 of Record
Company Name Cit of Charlotte Contact Name James Fatula
(if applicable) Y
Mailing Address 600 E. 4th Street
City Charlotte State NC Zip 128202
Phone [phone] Email [e-mail]
Landowner 2 of Record
Company Name Contact Name
(lf applicable)
Mailing Address
City State Zip
Phone Email
8. Indicate the Deed Book and Page number where the deed or instrument is filed. Attach a list of additional deeds
if applicable.
Deed Book Page Deed Book Page Deed Book Page
36349 398-402
I
Rev. 8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre-Con Meeting By: Page 1 of 2

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FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM
Soil Erosion and Sedimentation Control Ordinance v o R T FH CAR o t.Y N A
PART B — FRO AND NC REGISTERED AGENT
I. Person(s), firm(s)or Company who is/are financially responsible for this land-disturbing activity.
Financially Responsible Party
Company Name(if applicable) Beltway 77 Phase I Owner,LLC Contact Name Richard Horn
Mailing Address 280 E. 96th Street, Suite 250
City Indianapolis State IN Zip 46240
Phone [phone] Email [e-mail]
2. If the Financially Responsible Party listed above does not reside in the state of North Carolina,they must
provide a designated North Carolina agent below. This agent must be registered with/on the NC Secretary of
State business re Yistr .
North Carolina Agent for Financially Responsible Party
NC Registered Agent Name CT Corporation Contact Name Karen Rozer
Mailing Address 160 Mine Lake Court, Suite 200
City Raleigh State NC Zip 27615
Phone [phone] Email [e-mail]
3. (Optional)Additional contact familiar with the site,who understands the plans, and may represent the company.
Site Contact's Name Jim Tully Email [e-mail]
Phone: Office 919-868-5859 Phone: Mobile same
PART C — SIGNATURE WITNESSED BY A NOTARY PUBLIC
DO NOT SIGN THIS FORM UNTIL YOU ARE IN THE PRESENCE OF A NOTARY PUBLIC
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. If the
Financially Responsible Owner is not an individual,this form must be signed 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 t e be any change in the information provided herein.
,_ //��
Printed Name / ]
l'}I bu; Title or Authority � 74/10172,GG4- /CG j'�'LG I!(_,
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Wet-Ink Signature Date ///b6/liL'23
I, lir-a- fki. r , a Notary Public of the County o i Ol-h h --
State of //'7 a k
y,G, , hereby certf that Ghau (N, h•— personally
appeared 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 G day of J V VY--G✓ . 20
DINA L RANDALL A � ���,�/
Notary Public-Seal Notar Signature
'! ,t1-611
Hamilton County-State of Indiana y g
Commission Number NP0727332
My Commission Expires Jun 16, 2028
My Commission Expires O P r �1,1
Rev. 8/2022 Page 2 of 2