NCC231519_FRO Submitted_20230517

'jai%
FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM -Town of. e
Soil Erosion and Sedimentation Control Ordinance NORTH CAROLINA
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 Party 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 relevant items on this form
must be filled out accurately and completely.
PART A- Complete All Fillable Fields
1. Project name Four Oaks Subdivision
2. Address of land-disturbing activity (number, street) 14520 Beatties Ford Rd Huntersville,NC 28078
3. Approximate date land-disturbing activity will begin aCk cc tap to enter a date. 6-1-23
4, Purpose of development Residential Farmhouse Choose an item. Other.1?m Cluster
5. Total acreage of land to be disturbed or uncovered 2.74-acres
6. Total site acreage 20.02
7. Landowner(s)of Record. Names listed must match the deed(s).Attach list of additional owners,if applicable.
Note: If the landowner of record is not the person(s)or firm(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
Lando sner 1 of Record
Name TLO Properties @ LKN,LLC Mailing 8942 Rosalyn Glen Rd
Contact Natne Kathy Day Address City: Cornelius
Title Owner State: NC Zip: 28031
Phone: Office/Main 707-668-9656 Street
Phone: Mobile Address City:
Email [e-mail] IfPO Box listed above State: Zip:
Lando«ncr 2 of Record
Name Mailing
Contact Name Address City:
Title State: Zip:
Phone: Office/Main Street
Phone: Mobile Address City:
Email If PO Box listed above State: Zip:
8. Indicate Book and Page number where the deed or instrument is filed Attach list ofaddt'!deeds if applicable
Deed Book 35067 Page 204 Deed Book Page
Deed Book Page Deed Book Page

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM unte�e
Soil Erosion and Sedimentation Control Ordinance NORTH C.A R O L I N A
PART B—Sections 1, 2 and 4 are required
1. Person(s)or firm(s)who are financially responsible for this land-disturbing activity. Note: If the Financially
Responsible Person(s) or Firm(s)has an out-of-state address,a North Carolina agent must be designated in
item 2,below.
Finaitcinlly Responsible Party
Person or Firm TLO Properties @ LKN,LLC
If Company or Firm, list name as listed on NC Secretary of State business registry
Mailing Address City: State: Zip: 8942 Rosalyn Glen Rd,Cornelius,NC 28031
Street Address City: State: Zip:
Required if PO Box listed as Mailing Address
Contact Name Kathy Day Email [e-mail]
Phone: Office 707-668-9656 Phone: Mobile
2. lithe Financially Responsible Party is not a resident of North Carolina,provide the information of the
designated North Carolina agent who is registered on the NC Secretary of State business registry.
\C Agent t'or Financially Responsible Part
Registered Agent Name Name as listed on NC Secretary ofState business registry
Mailing Address City: State: Zip:
Street Address City: State: Zip:
If PO Box listed above
Email Phone
3. (Optional)Additional contact familiar with the site,understands the plans,and may represent the company.
Site Contact's Name Email
Phone: Office Phone: Mobile
4. 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 Kathy Day Title or Authority Owner _
Wet-Ink Signature Date B 2-0 Z-
mimmimminimias=imm
j, !.l � �il� , a Notary Public of the Co y of / State
I
of Jc.c& aft11pe , hereby certify that 444 personally appeared
before me this day and being duly sworn acknowledged that the a ove form was executed by him/her.
Witness my hand and notarial seal, this 1 day of Az 20 .
(seal) Notary Signature tip< ....).ere5
My Commission Expires �� 2s'.1�