NCC221902_FRO Submitted_20220525

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U�`... z Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
° CA 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:
Royal Brass and Hose
2. Address of land -disturbing activity:
10701 Clear Creek Commerce Drive, Mint Hill, NC
3. Approximate date land -disturbing activity will commence: June 1
Month Day
4. Purpose of development (Residential, Commercial, Industrial, etc.): commermal
5. Approximate acreage of land to be disturbed or uncovered. 3.30
6. Total site acreage: 3.53
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #] Name: Albemarle Road Associates, LLC CIO Merrifield Patrick
Address: 2400 S Blvd Ste 300 CIO MPV Properties, Charlotte, NC, 28203
Telephone: [phone] Fax:
Email Address:
Owner 92 Name:
Address:
Telephone: Fax
Email Address:
2021
Year
S. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additiona). deeds or instruments as necessary):
Book 13307 Page 919-926 Book Page
Book Page
Book Page
Fomi Revised 12-2016
(continue on back or separate pages as necessary)

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s).financially responsible for this land -disturbing activity:
Person or Firm: Drew MacDonald
Address: 3731 Woodpark Blvd, Suite A, Charlotte, NC 28206
Telephone: [phone] Fax:
Email Address: d.mac @royal brassandhose_com
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.)
Drew
I, Clcrc-t C�j C
County of
certify that
CEO
Die
, a Notary Public of the
State of Inr)( �e , hereby
�i�1+1 U1 personally appeared
before me this day and under oath acknowledged that this forrn �was executed by him/her. r
Witness my hand and notarial seal, this �, day o 1 , ` p►l�r���� Notary Signature: Cfl�.► ����.�.• • • ••�4 -'',.
STATE •' G
My Commission expires: �J "' `"c am � :' OF 0
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L NOTARY ?
Mecklenburg County Land Use and Environmental Services Agency �i� � '' PUSLIc•' A,
2145 Suttle Ave. "
Charlotte, NC 28208-5237
Phone [phone]