NCC230365_FRO Submitted_20230214

r Mecklenburg County Soil Erosion and
x
" t Sedimentation Control Ordinance
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:
Clear Creek Office Warehouse Flex Project
2. Address of land -disturbing activity:
10855 Clear Creek Commerce Drive, Mint Hill, NC 28227
3. Approximate date land -disturbing activity will commence: November 31 2022
4
Month Day
Purpose of development (Residential, Commercial, Industrial, etc.); Industrial / office
5. Approximate acreage of land to be disturbed or uncovered: 4.41 AC
6. Total site acreage: 4.41 AC
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Berkshire Partners #29 LLC
Address: 215 Queens Road, Charlotte, NC 28204
Telephone: [phone]
Email Address: [e-mail]
Owner #2 Name:
Address:
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 37538 page 602-607
Page
:••7
q
Page
Page
Year
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land-disttr bing activity:
Person or Firm: Berkshire Partners #29 LLC
Address: 215 Queens Road, Charlotte, NC 28204
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 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.)
David Nance
P'
Signature
Managing Member
Title
/0- �/ ,
Date
I, L Gt✓U a Notary Public of the
County of C eb 4 rvrlJ , State of _FOAA 6'-s 1' K 'k, , hereby
certify that D a vi A H. N A rrc 2 personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and potatA seal, this 14)"% day of 0 robe/ , 20 2 Z .
Notary Signature:
"'My'Corgrpission expires:
d4j— jvv d—
NOTARY PUBLIC
'o North Carollne
he �°e L
y Commission Expires September 19, 2025
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
U : Charlotte, NC 28208-5237
CO
Phone [phone]
80�9paa �✓ Q49�flS:bY