NCC221266_FRO Submitted_20220404

Town of Huntersville
I��.M e Soil Erosion & Sedimentation Control Ordinance
NORTH C^R"T-',N" 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:
Fairhaven Drive Relocation
2. Address of land -disturbing activity:
16201 Poplar Tent Church Road Huntersville, NC 28078
3. Approximate date land -disturbing activity will commence
April 1 2022
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 2.45 Acres
6. Total site acreage: 240.845 Acres
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: Fairhaven LLC
Address: 12601 East US HWY 60 Gold Canyon, AZ 85118
Telephone: [phone]
Email Address: jeffreysiegel01 @gmail.com
Owner #2 Name:
Address:
Telephone:
Email Address:
Fax:
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 28297 page 174 Book Page
Book Page 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: BCLA Huntersville, LLC
Address: 3115 Lion Lane, Ste 300
Telephone
Salt Lake City, UT 84121
801-830-8300
Email Address: scott(cbschooldev.us
Fax:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Registered Agents Inc.
Address: 4030 Wake Forest Rd, Ste 349
Raleigh, NC 27609
Telephone
Email Address:
0Va11Ifa1K
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 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)
Scott Brand
Prinle am
Signature
I
Manager
Title
3 3 2
Date
�ll a Notary
v `� L+ � , G�� , State of V ` , Public of the County of �- hereby
certify that SGc�+ Ply-k A personally appeared
before me on this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and nota! se�� 213'g-' day of A 0,* 1 , 20 22
Notary Signature:
My Commission
*:"'�
JACQ.UELINE WIL50N
Notary Public - State o! Utah
Comm, No. 710578
My Commission Expires on Town of Huntersville
Feb 14, 2024 PO Box 664
1.05 Gilead Rd., Ste 300
Huntersville, NC 28070