NCC241196_FRO Submitted_20240418

Mecklenburg County Soil Erosion and
; Sedimentation Control Ordinance
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, 41Pe : 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
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1. Project where land-disturbing activity is to be undertaken: 5 22 q ( /d h 1 e,
(,feu r{.o H( , IJC) 20 Z 2
2. Address of land-disturbing activity: S229 esAnttyl brr, l%l 1U .j
G, 297l,�
• 3. Approximate date land-disturbing activity will commence: (k f t f O 21014
4. Purpose of development(Residential,Commercial,Industrial,etc.):n1 Q i D 2N+)CA
5. Approximate acreage of land to be disturbed or uncovered: i 4 T C re
6. Total site acreage: d 1 q0
7. Landowners of record(use blank pag s to list additional owners as necessary):
Owner#1 Name: n a m A hi .Q%C� /1� LL G
Address:'Val C VYI a✓11/1.2u 1}i� Av`Q ef/1a rto+-i€, Mc)
22Q.os
Telephone: &'1"1 - 62-0- 3 2 22 C Fax:
Email Address: GO aC-4 . i&) CaPawi de1e(op- con
Owner#2 Name:
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 3Q 16f 1 Page 3 7 Book Page
Book Page _ Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016
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Continue-Financial Responsibility/Ownership Form ,
PART B
1. Person(s)or firms)financially r sponsible for this land-disturbing activity:
Person or Firm: -0h A i and I St 9 �� " n�_
Address: 71211 Lom ryi()Aiwa I+1�t Give, ( h(I foi2/ 1JC
2 212D5- f�
Telephone: 6 ii - '2 O- 3-2 5 Fax: g.:
Email Address: V IYGI C�-S� C((y�(,1 yyk �,Q .lo�[gy•
.
2. North Carolina agent for the person or firm who is financially responsible: Ii)
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Person or Firm: A pin Y *t fC j('i !
Address:2 411 CA 1'YI O YI(M Ve lT V1 a1V C ,i)
Telephone:_y1 CI — S-0 —322 5 Fax: :j
Email Address:
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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.)
4Ot'V\ -1C S M bt itct, PX
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Printed N. 4
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Sif .
:4. , Date
I, v UL'' 4 C r ' k' 1 v` 'e'e- ,a Notary Public of the
County of h'1eC [2 V1 by( State o ND( V` l_C�l rV 111\C ,^
, ,hereby �.
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certify that J0V11t h 7140 reluS ti C4 rdi S*I ,. personally appeared N
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before me this day and under oath acknowledged that this form was executed by him/her. n
A )\Witness my hand an o seal, of ,20 Zq -
Notary Signature: �1 �( l ��o t t i t t r ii,
(,cam • ;` G'N�
My Commission expires: 2 O5 g - ,1,-...,..• '• - P
: NOTAR}-G�
Mecklenburg County Land Use and Environmental Services Ageytjt. PUMA •rrl
2145 Suttle Ave. ,�•
Charlotte,NC 28208-5237 %fr4 • ��a%.`
Phone[phone] '/ire,i C'i `•‘�