NCC216536_FRO Submitted_20211122

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Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
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, allorth Carolina agent must be assigned.
Please Type or Print
PART A
1. Project where land -disturbing activity is to be undertaken:
St. Luke Catholic Church - Phase 2
2. Address of land -disturbing activity:
5832 Fairview Road, Mint Hill, NC
3. Approximate date land -disturbing activity will commence: 06 15 2021
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Institutional - Church
5. Approximate acreage of land to be disturbed or uncovered. 11.73 Acres
6. Total site acreage: 30.14
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Bishop Peter J. Jugis
Address: 1123 S. Church Street
Charlotte, NC 28203
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone:
Email Address:
Fax:
S. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 26655 page 104 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016 //1

Continue - Financial Responsibility/Ownership Form
PART B
Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Bishop Peter J. Jugis
Address: 1123 S. Church Street
Charlotte , NC 28203
Telephone:
704-370-3387
Email Address
Fax:
[e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Emmett Sapp
Address: Same as Above
Telephone;
704-370-3387
Email Address
Fax:
[e-mail]
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.)
Printed Name
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Signature
Title
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Date
._) 6�e,. M �ZC 1 k}' , a Notary Public of the
County of lJ Ns" tZ , State of _ Off al- Cow O` 1 C1 C-. , hereby
certify that rP&A-f-C S • I'tk t 5 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 � _ day of C�OC ► 20 _.
Notary Signature: N� wn,%
My Commission expires:
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte, NC 28208-5237
Phone [phone]
1 � �
My comm. Expires -
July 6. 2021
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