NCC222105_FRO Submitted_20220607

Nau
Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
f
Financial Responsibility/Ownership Form
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:
Bailey's Forest Phase III
2. Address of land -disturbing activity:
18429 Barnhardt Road
3. Approximate date land -disturbing activity will commence: 100
4.
5
10
Month
Purpose of development (Residential, Commercial, Industrial, etc.): Resideniiai
Approximate acreage of land to be disturbed or uncovered: 5.7
Total site acreage: 6.5
01 21
Day Year
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Bailey Forest Development, Inc.
Address: 19520 West Catawba Avenue, Suite 200
Cornelius, NC 28031
Telephone: [phone]
Email Address: [e-mail]
Fax:
Owner #2 Name: Forestyle, LLC
Address: 19520 West Catawba Avenue, Suite 200
Cornelius, NC 28031
Telephone: [phone]
Email Address: [e-mail]
Fax: 704-
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 32968 page 632 Book 32639 page 697
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Bluestream Partners, LLC
Address: 19520 W. Catawba Avenue, Suite 200
Cornelius, NC 28031
Telephone: [phone]
Email Address: [e-mail]
Fax: [phone]
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.)
�. �; _ Mahag��
Printed Name Title
2d
Signature Date
I, �tIm .S. n a Notary Public of the
County of ILIwig V , State of 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 rotarial seal, this Aaa day of , 2(*-.
Notary Si
My Commission
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave. IQMBERLY JEAN HATFIR D
Charlotte, NC 28208-5237 Notary Pubic North Carolina
Phone [phone] Iredell County
My Commission Expires
June 08, 2026