NCC223203_FRO Submitted_20220915

Town of Huntersville
Jitm °f ' e
Soil Erosion &Sedimentation Control Ordinance
NORTH CAROLINA 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.
PART A
1
2
Please Type or Print
Project where land -disturbing activity is to be undertaken: Huntersville
Address of land -disturbing activity: 7630 Oliver Hager Road, Huntersville, NC 28078
3. Approximate date land -disturbing activity will commence: 12 01 2022
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 65.00
6. Total site acreage: 92.41
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: Sara Louise Holloway
Address: 7602 Oliver Hager Rd., Huntersville, NC 28078
Mailing: !41 Cahill Dr., Winchester, VA 22602
Telephone:
Email Address:
Owner #2 Name: Jack R. Hailey
Address: 15510 N C 73 HY, Huntersville, NC 28078
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 3532 Page 368 Book Page
Book 28059 Page 957 Book Page
11/19

7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: Harold L. Hailey
Address: 15510 N C 73 HY, Huntersville, NC 28078
Telephone: _
Email Address:
Fax:
Owner #2 Name: Ginger D. Eyerheart
Address: 15510 N C 73 HY. Huntersville. NC 28078
Telephone:
Email Address:
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 28059 Page 957 Book Page
Book 28059 Page 957 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: MI Homes of Charlotte, LLC
Address: 5530 77 Center Drive
Charlotte, NC 28217
Telephone: [phone]
Email Address: [e-mail]
Fax:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: MI Homes of Charlotte, LLC
Address. 5530 77 Center Drive
Charlotte, NC 28217
Telephone: [phone]
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 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)
Cody Simoneaux VP of Land Development
Prin el Ime Title
Si n re Date
I, ll a Notary
Public f the County of �1n�y. ' State of hereby
certify that personally appeared
before me on this ay and under oath acknowledged that this form was executed by him/her.
Witness my han and aria seal, this day 20 C
21
Notary Signatur
My Commission Expires. - 2'
Town of Huntersville
PO Box 664
105 Gilead Rd., Ste 300
Huntersville, NC 28070