NCC230918_FRO Submitted_20230403

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Mecklenburg County Soil. Erosion and
' Sedimentation Control Ordinance
"ram �A o Fina vial Responsibility/Ownership Form
No person shall initiate any land-dis
County, Mint Hill or Davidson S
completing and filing this form w
Services. The financially responsible
of Violation or related documents fc
financially responsible party is out of
PART A
1. Project where land -disturbing
2. Address of land -disturbing activi
3. Approximate date land -disturbing
4. Purpose of development
5
7
Approximate acreage of land to t
Total site acreage: 5.07 acres
Landowners of record (use blank
Owner #1 Name: Ezequiel Ra
Address: 11711 Dunham Dril
Matthews, NC 28105
arbing activity covered by Section 6 of the Mecklenb
dimentation and Erosion Control Ordinances prior
th Mecklenburg County Land Use and Environmei
party will be on record as the party to accept any Noti
any non-compliance with the above Ordinances. If
hate, a North Carolina agent must be assigned.
Type or Print
is to be undertaken: Ramos Residence
1647 Sweetgam Lane, Matthews, SEC
AP ril 15 2022 �f
activity will commence:
Month Day Year
al, Commercial, Industrial, etc_): Residential
disturbed or uncovered. 0.24 acres
os
to list additional owners as necessary):
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner #2 Name: Jessica Was Ikowski
Address: 11711 Dunham Drive
Matthews, NC 28105
Telephone:
Email Address:
Fax:
S. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 35036 page 203 Book Page
Book Page Book Page
(continue on luck or separate pages as necessary)
Form Revised 12-2016

PART B
Continue - Financial Responsibility/Ownership Form
1
Person(s) or firm(s) financially
Person or Firm: Z&E Constri
Address: 12480 Grey Corr'
Midland, NC 28107
Telephone: [phone]
Email Address: zandecons
2. North Carolina agent for the I
Person or Firm: NA
Address:
Telephone:
Email Address:
3. The above information is true an
provided by me while under oath
person if an individual or by an
with authority to execute rostrum,
an individual.)
Gabrielle Palombaro
Printed Name
ijulz - . -
Signature
1, lWIIV[ Iltlic IVI.
County of
certify that
before me this day and under oath a
Witness my hand and notarial seal,
Notary Signature:
My Commission expire
)nsible for this land -disturbing activity:
n Co Inc; Gabriel Palombaro
rcia[ Drive
Fax:
[e-mail]
or firm who is financially responsible:
correct to the best of my knowledge and belief and
(This form must be signed by the financially responsi
fficer, director, partner, attorney -in -fact, or other per
Es for the financially responsible company or entity, if
President / Z&E Construction
Title
3 3f
Date
a Notary Public of
State of
Vjq(-4 V personally app
awledged that this form was executed by him/her.
��- — day of �A lILI , 20 2
Mecklenburg Count3 Land Use and Environmental
2145 Suttle Ave.
Charlotte, NC 28208-5237
Phone [phone]
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