NCC221503_FRO Submitted_20220421

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4 c x Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
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Financial Responsibility/Ownership Form
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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: Matthews Mint Hill Workforce Townhomes
2. Address of land -disturbing activity: 2026 Matthews -Mint Hill Road, Matthews, NC 28105
3. Approximate date land -disturbing activity will commence: December 15 2021
Month Day
4. Purpose of development (Residential, Commercial, Industrial, etC.): Residential
5. Approximate acreage of land to be disturbed or uncovered. 7
6. Total site acreage: 9.39
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Richard Harkey
Address: 3323 Rustburg Drive, Fayetteville, NC 28303
Telephone: ��/, Fax: _
Email Address: r• r) 1 1 ar 1� @ g m d i I. w yn
Owner #2 Name: John Harkey
Address: 3323 Rustburg Drive, Fayetteville, NC 28303
Telephone:
Email Address:
Fax:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
Year
additional deeds or instruments as necessary):
�a
Book 10963 page 901 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: TBC Development, LLC
Address: 272 West Coleman Blvd, Suite 200, Mt. Pleasant, SC, 29464
Telephone:
803-242-0566
Email Address: [e-mail]
Fax:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Tony Berry
Address: 272 W Coleman bled, Suite 200, Mt Pleasant, SC, 29464
Telephone:
803-242-0566
Email Address: [e-mail]
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.)
To nv Be
Printed Name
Signature
Manager
Title
08/02/2021
Date
1, "?0_U.. \e_e_n (\'� . `I 0" , a Notary Public of the
County of C , State of SC_ , hereby
certify that
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 a day of �Cl, U , 20 : I
Notary Signature: \ a'A-c,Qph, m - *<A:: ,•o�� ,�v RA
y: •''
My Commission expires:
NOTARY
Mecklenburg County Land Use and Environmental Services Agency PUB00 •3
2145 Suttle Ave. s'•.
Charlotte, NC 28208-5237 0. •...... ,N•.�
Phone [phone] '''-.,,',!.CAR .o'-'