NCC220293_FRO Submitted_20220114

Town of Huntersville
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Soil Erosion &Sedimentation Control Ordinance
NORTH CAROLINA Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity as defined in the Town of Huntersville Soil
Erosion and Sedimentation Control Ordinance prior to completing and filing this form with the Town
of Huntersville. The financially responsible party will be on record as the party to receive any
Notices of Violation or related documents related to non-compliance issues with the above
Ordinance. By filing this form, the parties are not relieved from any other permits that may be
required for the Project. 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. Beltservice Building Expansion
2. Address of land -disturbing activity: 9540 Julian Clark Avenue; Huntersville, NC 28078
3. Approximate date land -disturbing activity will commence: January 10 2022
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 1.21 acres
6. Total site acreage: 5.328 acres
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: PAAK-EM, LLC co/ Beltservice Corporation
Address: 4143 Rider Trail North
Earth City, MO 63045
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone:
Email Address:
Fax:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary)
Book 10641 page 920 Book Page
Book Page Book Page

Financial Responsibility/Ownership Form - Continued
PART B
Person(s) or firm(s) financially responsible for this land -disturbing activity:
Persons or Firm: PAAK-EM, LLC c/o Thomas Acker
Address: 4143 Rider Trail North
Earthy City, MO 63045
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Beltservice Corporation c/o Jay McNeary
Address. 9540 Julian Clark Avenue
Huntersville, NC 28078
Telephone: [phone] Fax:
Email Address: [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 is 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)
Thomas E. Acker
Printed ame
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Signature
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Title
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Date
1, � V\ ���l�,�f�, 1'N cox a Notary
Public of the County of �.�, P�f�C'S State of Mi'(.SOhereby
certify that atmy L Kcyu personally appeared
before me on this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this
r� �f;,day of ) 01 L4 r!4 , 20 -2
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Notary Signature: ajj'(ra ly ���l4u
My Commission Expires:
�K-1-
ALLISON CLAIRE WILCOX
Notary Public, Notary Seal
State of Missouri Town of Huntersville
St. Charles County p0 Box 664
Commission # 19659371
My Commission Expires 09-12-2023 105 Gilead Rd., Ste 300
Huntersville, NC 28070