NCC241796_FRO Submitted_20240618

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM GeThintelsvili"fie
Soil Erosion and Sedimentation Control Ordinance NORTH CAROLINA
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.
Financially Responsible Party
Person or Firm Park Huntersville LLC (Maya Hotels)
If Company or Firm, list name as listed on NC Secretary of State business registry
Mailing Address 8632 Wilkinson Blvd City: Charlotte State: NC Zip: 28214
Street Address City: State: Zip:
Required if PO Box listed as Mailing Address
Contact Name Parimal Thakor Email [e-mail]
Phone: Office Phone: Mobile [phone]
2. If the 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.
NC Agent for Financially Responsible Party
Registered Agent Name Name as listed on NC Secretary of State 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 Alex Quesenberry Email [e-mail]
Phone: Office 7048876586 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 inform ion should there be any change in the information provided herein.
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Printed Name t )�Ci, ii)L— ��IItFKa� Title or Authorityf
Wet-Ink Signature "/v-0 Date /o/22/
I, veronica_ C\eeSe cro. a Notary Public of the County of Nlkckj e nhLlt'�J , State
of Noc* 'Act_Carol t 'Act_ , hereby cert that Rr; nic Tb kpr personally appeared
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this o2 r-I day of DC- ohe r , 20 ate.
VERONICA M CHEESEBORO
Notary Publi A rth Carolina Not Signature
Mockler uatfCounty �7 g
My Commission Expires
December 03,2022 My Commission Expires -beeeniber 3, 20,�2-
Rev.6/2022 Page 2 of 2

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM i inte�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 P
2. Address of land-disturbing activity (number, street) 13360 Reese Blvd East
3. Approximate date land-disturbing activity will begin 10/10/2022
4. Purpose of development Commercial Other:
5. Total acreage of land to be disturbed or uncovered 2.90
6. Total site acreage 4.04
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.
Landowner 1 of Record
Name Park Huntersville LLC Mailing 8632 Wilkinson Blvd
Contact Name Parimal Thakor Address City: Charlotte
Title Vice President State: NC Zip: 28214
Phone: Office/Main Street 8632 Wilkinson Blvd
Phone: Mobile [phone] Address City: Charlotte
Email [e-mail] If PO Box listed above State: NC Zip: 28214
Landol‘ner 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'1 deeds if applicable
Deed Book 65 Page 481 Deed Book Page
Deed Book Page Deed Book Page
Rev.6/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre-Con Meeting By: Page 1 of 2