NCC241194_FRO Submitted_20240418

+ Mecklenburg County Soil Erosion and
" ESA Sedimentation Control Ordinance
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1 Financial Responsibility/Ownership 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 be assigned.
Please Type or Print
PART A
1. Project where land-disturbing activity is to be undertaken: �j3 11 0.urvt br,
evvictiotie- Nc, Z gLZ�
2. Address of land-disturbing activity: 1;3 i I ( (k(d 'l {` t Q_(Act
3. Approximate date land-disturbing activity will commence: N e>n L d 2O2)
Mon Day �Ye-ar61
4. Purpose of development(Residential,Commercial,Industrial,etc.): �Q S j dp, ,-k l o.0
5. Approximate acreage of land to be disturbed or uncovered: 0 f,3(6 tkL S
6. Total site acreage: 01 i
7. Landowners of recor (use blank pages to list additionalowners as necessary):
D
Owner#1 Name: (( ��YYI v lDpr &t/ i` Lic
Address: Z42' (O✓l�i'�'lo/1 M?cl i\ve ( 4a Q`Lo He
2620
Telephone: 6 q y 5 zO- .3225 Fax:
Email Address: Co►lY1YCt C [a mA wick velo e W
Owner#2 Name: r
Address:
Telephone: Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed(use blank pages to list
additional deeds or instruments as necessary):
Book 30 (el I Page '$ Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

I
Continue-Financial Responsibility/Ownership Form
PART B
1. Person(s)or firm(s)financially responsible for this land-disturbing activity:
Person or Finn: 10 k 11 tiCt(U I.S-f 9 Address: 2 I Z Y CO M m o)11 MP CI I f/ (AVP, Oj/1a te,0i C
2g2Ds
Telephone: 6 li - 52 0- 322 5 Fax:
Email Address: Cb N 1YU C 1l.& CO, C(AKA \ de 1Q top (1Y1' k
2. North Carolina agent for the person or firm who is financially responsible:
N I 1 �, `._,11
Person or Firm: �Ot�I� l l�Cd1(+ 1 I Address:7 4).1? LO rY10'Yl Oyl 1AGU [t/t ( l G u 1�C
1 Z Z`0.;"
i Telephone: 6110 — 9-1-0 —322 S. , Fax:
Email Address:
1 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
Vwith authority to execute instruments for the financially responsible company or entity,if not
an individual.)
3 10 16 , P�1461CA(
Printed N e Title
i 9
i Si a Date
I, Uc L cx C 2016 Z v(Le (� U�.,a Notary Public of the
County of ��Q(,vt Q✓l by 9 ,State of lt�(*1A `,u r1 acA ,hereby
( h 1 certify that •�O A 14'0 roUS ', G WI S ii ._ personally appeared
before me this day and under oath acknowledged that this form was executedp by him/her. ,,
Witness my hand an of seal, s ( ( dv of Apr\ 1L ,20 2_,---1 .
Notary Signature: / �`��GU LA •
�\��ttttt►/iii�
2
GONZAZ
My Commission expires: I2 11J5 1 • ;4., ��•�"'•`� ��� `'
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Mecklenburg County Land Use and Environmental Services Alcgtz}t CI ;r71
2145 Suttle Ave. plJBl1 •'�'
Charlotte,NC 28208-5237 ;,t,FC'•.,,,,,,.•.. I'.:
Phone[phone] ,",��HgCAR�`\\•