HomeMy WebLinkAboutNCC221243_FRO Submitted_20220401Town of Huntersville
,,6T
e Soil Erosion & Sedimentation Control Ordinance
NORTH CAROLINAFinancial Responsibility/Ownership Form
No person shall initiate a-)y 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:
Black Farms Road Farmhouse Cluster
2. Address of land-d sturbing activity:
14700 Black Farns Road, Huntersville* NC 28078
3. Approximate date land -disturbing activity will commence:
10 02 2021
Month Day Year
4. Purpose of deveIc pment (Residential, Commercial, Industrial. etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered; 6.00 acres
6. Total site acreage 12.27 acres
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: Black Farms Collective, LLC
Address: 8512 S iadetree St, Huntersville, NC 28078
Telephone: 704 301-8082 Fax:
Email Address: ron@loveshutter.com
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 cr instruments as necessary)
Book 35366 gage 41 Book Page
Book ",age Book Page
Financial Responsibility/Ownership Form - Continued
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Persons or Firm: Black Farms Collective, LLC
Address: 8512 Shadetree St, Huntersville, NC 28078
Telephone: 704-301-8082
Email Address: ran@loveshutter.com
Fax:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
Email Address:
Fax:
3. The above inforrr ation 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 E xecute instruments for the financially responsible company or entity, if not
an individual)
Ron Randles
Printed Name
r
Signature
Title
Date
a Notary
Public of the County of _ M i t -,, State of / r hereby
certify that personally appeared
before me on this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial sea[, this day of L "142 20,A j
Notary Signature:
My Commission Expires:
3 IZ,27- 3
Town of Huntersville
PO Box 664
105 Gilead Rd., Ste 300
Huntersville, NC 28070