NCC230446_FRO Submitted_20230228

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FRO FORM i��MkSHIl' cI of. e
FINANCIAL RESPONSIBILITY OWNER
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
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 Course
16500 Birkdale Commons Parkway
Feb. 17, 2023
Pond Remediation
2.62
82.22
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 I
Record
Company Name
Lake Norman Real Estate
of
Contact Name Trent Gustafson
If applicable
Investors, LLC
Mailing Address
P.O. Box 12170, Charlotte, NC 28220
Physical Address
5960 Fairview Road, Suite 327, Charlotte, NCX8%10
I PO Box listed above
Phone
7045616295
Email [e-mail]
Lando-vvner
2 of Record
Company Name
Contact Name
If applicable
Mailing Address
Physical Address
I PO Box listed above
Phone
Email
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
Rev. 8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre -Con Meeting By: Pagel of 3

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM
Soil Erosion and Sedimentation Control Ordinance
PART B — FRO AND NC REGISTERED AGENT
41mir-He
NORTH CAROLINA
Person(s), firm(s) or Company who is/are financially responsible for this land -disturbing activity.
Company Name (ifapplicable)
Financially Responsible
Lake Norman Real
Estate Investors, LLC
PartN
Contact Name Trent Gustafson
Mailing Address
P.O. Box 12170, Charlotte, NC 28220
Physical Address
I PO Box listed above
5960 Fairview Road, Suite 327, Charlotte, NC 2
Phone
7045616295
Email
[e-mail]
2. If the Financially Responsible Party 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 Carolina 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
DO NOT SIGIN THIS FORINil UNTIL YOU ARE I\iT1-JE PRESENCE OF A INIOTARY PUBLIC
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 �ih/-- Title or Authority /I✓J,r,✓,d��..�e, �f7t.
Wet -Ink Signature Date --7 Zp Z�-f
I, Ark-- rS a Notary Public of the County of J- zck (-en bu rot
State of iV�a p( hereby certify that %1i— .4yfVX I��� J personally
appeared befo `� PlFis'a'aP,*ing duly sworn acknowledged that the above form was executed by him/her.
Witness my hsind anahvum peal, kis 01 day of f cbruq rtl 20.
MY
COMMISSION EXPIRES
0.
�yl�ACCUBLIG?� Notary Signature
'§!N,RG�uCOVa a``•
Rev. 8/2022 Page 2 of 3

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM
Soil Erosion and Sedimentation Control Ordinance
My Commission Expires
(,/iLl /U27
��own of • �i
NORTH CAROLINA
Rev. 8/2022 Page 3 of 3