NCC241810_FRO Submitted_20240617

Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance�� Financial Responsibility/OwnershipForm
. .�
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: TRiNRAs Su6AttiZsi oh,
Pg�) : t 13-N4.S4 4 Px) tcl AU 61
2. Address of land-disturbing activity: 29 0 11;AAsS AkAIt1Q.u&e.Mei 2Rln.s
3. Approximate date land-disturbing activity will commence: ,UQU _Z_`? Z02-3
Month Day Year
4. Purpose of development(Residential,Commercial,Industrial,etc.): ikcg;apart A
5. Approximate acreage of land to be disturbed or uncovered: 2.8 0 .A tQ e.5
6. Total site acreage: 5.03 A Ga.eS
7. Landowners of record(use blank pages to list additional owners as necessary):
Owner#1 Name: Ca.roLlevso 1
Address: 2 - i‘te. Z�eSiA,u At Q Sc., - c�
TA1 e)AL) QAal Air,/ 280-
Telephone: COL/- 804- ODo Fax:
Email Address: J.o S e o sa.,
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 b$31/c Page 363 —3 5$ Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue-Financial Responsibility/Ownership Form
PART B
1. Person(s)or finn(s)financially responsible for this land-disturbing activity:
Person or Firm: CRC° t( L.Lc ll
Address: it At` C�1DS}��.,t�t
Telephone: 3.o`i-go 3- -00a* Fax:
Email Address: to Se. a0 d05A�1 Gofp,Co,t t�
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax:
Email Address:
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.)
(Sow- rv+uv►g�eZ titeM6eI.
Printed Name Title
ftt A-(
Signature a2/t 072 3
Date
I, k lo-Fu- 2 SH,1H , a Notary Public of the
County of Mtockteli bard ,State of nloY4-6l Coro l j t,q hereby
certify that -soSG M 4.6'6L w►tifv QC/C2 personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal,this /041 day of Ter_ ,20 20&
Notary Signature: ktud,hct
My Commission expires: 0/-- 19 202$
���aaiiuuru,
Mecklenburg County Land Use and Environmental Services Agency Notary Public
2145 Suttle Ave. _ Mecklenburg
Charlotte,NC 28208-5237 = County
Phone[phone] My Comm.Exp.
y 01-18-202s sr