NCC233001_FRO Submitted_20231006

Nlecklenburg County Soil Erosion and
•
t. t • Sedimentation Control Ordinance
'71***. Financial Responsihility/(hinership 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 he assigned.
Please Type or Print
PART
1. Project where land-disturbing activity is to be undertaken: StoryHill Church
2. Address of land-disturbing activity: 480 S Main Street, Davidson NC 28036
3. Approximate date land-disturbing activity will commence:
Month Day Year
4. Purpose of development (Residential,Commercial, Industrial,etc.): Commercial, Institutional
5. Approximate acreage of land to be disturbed or uncovered: 3.63
6. Total site acreage: 4'11
7. Landowners of record(use blank pages to list additional owners as necessary):
Owner#1 Name: Storyhill Church, Inc.
Address: P.O. Box 325 Davidson NC 28036
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner#2 Name: Davidson Legacy Partners, LLC
Address: 19824 W Catawba Ave Suite G, Cornelius NC 28031
Telephone: [phone] Fax:
Email Address: [e-mail]
8. Indicate Book and Page where the deed or instrument is tiled(use blank pages to list
additional deeds or instruments as necessary):
Book 37548 page 872 Book 37498 page 012
Book 36915 page 105 Book Page
(continue on back or separate pages as necessary)
Form Revisal 12-2016 _�

Continue - Financial Responsibility/0 nership Form
PART B
1. Person(s)or firm(s)financially responsible IIfoo-r this land-disturbing activity.
Person or Firm: 5rorylnt �� ClitlYch
Q
Address. �l V O S- Kam n 9i'e l- D.w i G1so rj Z$03,
MAtttni a miss P 0 6o',t 3.5 )44vtdser ,NG X036)
Telephone 7 0 4 - 127- `t 02. Fax:
Email Address: 6011610 Kathy, fiett eicIoud •LOW)
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax:
Email Address:
3. l'he 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.)
M C-tto,l clo.k-e Packo r
Printed Name Title
L/Ll Z3
Si ture Date
/gyp ,a N t Public of the
County of j��> ,/i7t, 4� , State of /I/�rf k G� r%-c�'t , hereby
certify that �A cue l /aK personally appeared
/,�i PPe
before me this day and under oath acknowledge that this form f was executed by him/her.
Witness my hand and not• i I eal t is ^ day of ir_Z--t-oe - , 20 .�13
Notary Signature:
My Commission expires: /? r /� Z d t
v�Pe▪ pTA lF��
Mecklenburg County Land Use and Environmental Services AgencR • �.� ,U
2145 Suitle Ave.
Charlotte,NC'28208-5237 ▪ (Ig�
Phone[phone] ;'�� •, '•
"it 7BURG c° `'