NCC223577_FRO Submitted_20221019

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORMh To"
Soil Erosion and Sedimentation Control Ordinance NORTH C A R o L I N A
Instructions: No person shall initiate any land -disturbing activity on one or more acres, as covered in the Town of
Huntersville Soil Erosion and Sedimentation Control Ordinance, before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Huntersville. The Financially
Responsible Parry will be on record as the party to accept any Notices of Violation or related documents for any non-
compliance of the Town of Huntersville Soil Erosion and Sedimentation Control Ordinance. If the Financially
Responsible Party resides out of state, a North Carolina agent must be assigned. All items on this form must be
filled out accurately and completely.
PART A - PROJECT AND LANDOWNER INFORMATION
1. Project name
2. Address of land -disturbing activity (number, street)
3. Approximate date land -disturbing activity will begin
4. Purpose of development (Commercial, Residential,
Industrial, etc.)
5. Total acreage of land to be disturbed or uncovered
6. Total site acreage
Birkdale Golf Club Mixed -Use (Birkdale Place)
16580 Birkdale Commons Parkway
November 1, 2022
Commercial, Residential
18.70
15.64
7. Landowner (s) of Record. The names listed below must match the Deed(s). Attach a list of additional owners, if
applicable.
Note: If the landowner of record is not the person(s) firm(s), or Company's Financially Responsible Party,
as listed in Part B, item 1, a separate Letter of Consent, signed and dated by the Landowner of
Record, or their Authorized Agent, is required.
Landowner of i
Company Name
Lake Norman Real Estate Contact Name
Trent Gustafson
If applicable
Investors, LLC
Mailing Address
5960 Fairview Rd, Ste 327, Charlotte 28210
Physical Address
16580 Birkdale Commons Prkwy,Huntersville28078
I PO Box listed above
Phone
7049533104 Email
[e-mail]
Landowner
Company Name
Lake Norman Real Estate Contact Name
Trent Gustafson
If applicable
Investors, LLC
Mailing Address
5960 Fairview Rd, Ste 327, Charlotte 28210
Physical Address
16500 Birkdale Commons Prkwy,Huntersville28078
I PO Box listed above
Phone
7049533104
Email
[e-mail]
Indicate the Deed Book and Page number the deed or instrument is filed. Attach a list of additional deeds if
applicable.
Deed Book Page
Deed Book Page
Deed Book Page
37334
653
37331
924
37334
642
37331
936
Rev. 8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre -Con Meeting By: Page 1 of 3

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM
Soil Erosion and Sedimentation Control Ordinance
PART B - FRO AND NC REGISTERED AGENT
e �of. e
NORTH CAIZOLINA
Person(s), firm(s) or Company who is/are financially responsible for this land -disturbing activity.
Financially Responsible
Party
Company Name (if applicable)
Birkdale Real Estate
Contact Name Trent Gustafson
Investors, LLC
Mailing Address
5960 Fairview Rd, Ste 327, Charlotte 28210
Physical Address
I PO Box listed above
Phone
7049533104
Email
[e-mail]
2. If the Financially Responsible Parry listed above does not reside in the state of North Carolina, they must
provide a designated North Carolina agent below. This agent must be registered with the NC Secretary of State.
North I. Agent for Financially Responsible Party
NC Registered Agent Name Contact Name
Mailing Address
Physical Address
I PO Box listed above
Phone Email
3. (Optional) Additional contact familiar with the site, who understands the plans, and may represent the company.
Site Contact's Name Email
Phone: Office Phone: Mobile
PART C — SIGNATURE WITNESSED BY A NOTARY PUBLIC
�• • •' • •• •NOTE QWi
The above information is true and correct to the best of my knowledge and belief and was provided by me under oath.
(This form must be signed by the Financially Responsible Person, if an individual, or his attorney -in -fact. If the
Financially Responsible Owner is not an individual, this form must be signed by an officer, director, partner, or
registered agent with the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Printed Name / ` !-rf7�'i+%�o"� Title or Authority A&vA1&#= ^;
Wet -Ink Signature Date
DateLoor �O
I, 0hut of A. Mau Finrer a Notary Pztblic of the Coatnty off (�
State of KncA h ('q,f'Dba hereby certify that 1 reAA C-yj40XSD0 personally
appeared before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this (L4{h day of 201L_.
DAVID A. MONTES FLORES
NOTAF(WPI)BLIC
Mecklenburg County North Carolina Notary Signature J ModMy Commission Expires Jan. 23, 2025
7YaYN 25
Rev. 8/2022 Page 2 of 3

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM
Soil Erosion and Sedimentation Control Ordinance
My Commission Expires
ikntemue���f.
NORTH CAROLINA
Rev. 8/2022 Page 3 of 3