NCC221214_FRO Submitted_20220329

ry ..�.. Mecklenburg County Soil Erosion and
E� Sedimentation Control Ordinance
?>M CA 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: CNSA
2. Address of land -disturbing activity: 10314 Hamptons Park Dr.
3. Approximate date land -disturbing activity will commence: January 15 2021
Month Day Year
4. Purpose of development (Residential, Commercial, Industriai, etc.): Midi-1
5. Approximate acreage of land to be disturbed or uncovered: 2.35
6. Total site acreage: 2.58
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Statesville Road Office, LLC
Address: 2400 South Blvd
Charlotte, NC 28203
Telephone: [phone] Fax:
Email Address: [e-mail]
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):
Book 29405 page 224 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Fonn Rcviscd 12-2016

Continue _ Financial Responsibility/Ownership Form
PART B
Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Statesville Road Office, LLC
Address: 2400 South Blvd
Charlotte, NC 28203
Telephone: 704•248.2100 Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
Email Address:
Fax:
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.)
George Macon Partner
ame
Title
11.16.21
Date
I, �i.C7t� �- /'r �c�✓ _, a Notary Public of the
County of Aft%t P_e�avfLry , State of Now-M Clo&O ta.ia , hereby
certifythat GtryRgd, N1nto,.� 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 1 4ILI day of Al&je nUM , 20 Zi
Notary Signatur���� 7% .
My Commission expires: 5 15 Zo�r_'TT P
OF
zMecklenburg County Land Use and Environmental Services A N o r,qR y
2145 Suttle Ave.
Charlotte. NC 28208-5237 US L I C 2c.=
Phone [phone]