NCC222071_FRO Submitted_20220604

ua Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
Financial Responsibility/Ownership Form
A �
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: Sedona Farms Common Drives
2. Address of land -disturbing activity: 15235 June Washam Rd, Davidson NC 28036
3. Approximate date land -disturbing activity will commence:
Month Dav Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): "esidennal
S. Approximate acreage of land to be disturbed or uncovered: 3.56 acres
6. Total site acreage: 62.41 acres
7. Landowners of record (use blank panes to list additional owners as necessary).
Owner #1 Name: Bi-Part Development, LLC
Address: 18611 Starcreek Rd, Cornelius NC 28031
Telephone: [phone] — -- — Fax: T-- _—_---
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone: Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed (tLse blank pages to list
additional deeds or instruments as necessary):
Book Page
Book Page
Book Page
Book Page
(continue on back or separate pages its necessary)
For%Recis-ed 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firms) financially responsible for this land -disturbing activity:
Person or Firm: BI-Part Development, LLC
Address: 18611 Starcreek Rd, Cornelius NC 28031
Telephone: [phone] Fax:
Email Address. [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax
Email Address:
3. The above information is true and correct to the best of my knowledge and belief and was
provided by me chile 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.)
Printed Nam I itt�
Signature Date
1, a Notary Public, of the
County of £' _ —,State of knf 4b pfa ala l �' hereby
certify that _PLi(VI)i2 Va�x�j1_1 personally appeared
before me this day and under oath acknowledged that this form was executed by himiher.
Witness my hand and notVial seal, tlyis(- y of
Notary Sign lure: - MBERI Y- JEAN-. - ATFIEL
Notary PuM,- Noft Caro**
My Cornmission e ires:
m N .
Mecklenburg County Land Use and Environmental Sen ces Ageno
2145 Suttle Ave.
Charlotte,'•.�f 28209-i-137
Phone [phone]