NCC230879_FRO Submitted_20230329

} �aU IVc Mecklenburg County Soil Erosion and
AV k ' l' Sedimentation Control Ordinance
Financial Responsibility/Ownership Form
OM C ARv
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
Project where land -disturbing activity is to be und
ertaken: OW a S_ r IS
2. Address of land -disturbing activity:
3. Approximate date land -disturbing activity will commence:
Month t 1 Days Jear
4. Purpose of development (Residential, Commercial, Industrial, etc.):
5. Approximate acreage of land to be disturbed or uncovered: 0. q l �p a. ex e_
6. Total site acreage: q. O 1 oic t e S
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner # 1 Name: 2- \.k V \ (Y\ Sh)VCA YA A LK
Address: �1� Col ,r� w��► AYe i iotl -1, a �0�
Telephone: -1y�A f °1q0� - 1 0 Fax:
Email Address: V 0- V CAD-f
Owner #2 Name: N a xt o 'nACIY-
Address.
qr\/\Q 'SAXA� CkYk JW C 0-
Telephone: �1 °`� �1� `� " ��5�1 Fax:
Email Address: 'n�04'i^�S� �(4
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book Ei!i�page `1 of i Book Page
Book Page Book Page
( continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: 1Z-�Jl v i
Address:
N. C
Telephone: -," — 1?9 ' `1 `t b (4 Fax:
Email Address: Cu N fVvr.,VA 1_ po cji I .
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.)
fn �m d I3oAi CA S �1 K n r] -P K
i'rinted Name
1,
OW ne �
Title
SIc0l��
Date
a Notary Public of the
County of Vy , 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 notarial seal, this � 6 day of ��, � , 20
Notary Signature:
YOOESH PATEL
My Commission expire . NOTARY PUBLIC
neon ounty
North Carolina
My Commission Expires 02117/2025
Mecklenburg County Land Use and Environmental Services Agency
C45 Suttle Ave.
Charlotte, NC 28208-5237
Phone [phone]