NCC242080_FRO Submitted_20240711

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,fr. -! �� Mecklenburg County Soil Erosion and
�j gni • Sedimentation Control Ordinance
1 4' ��s;> Financial Responsibility/Ownership Form
I 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
I completing and filing this form with Mecklenburg County Land Use and Environmental
IServices. The financially responsible party will be on record as the party to accept any Notices
I 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.
I
I Please Type or Print
i PART A
' 1. Project where land-disturbing activity is to be undertaken: 5 4?.6- l rd'e4,1 0 r,
I ( t-o+4-e, '.0 1 z$214 _ ���� �(� L � `(�
7 2. Address of land-disturbing activity: /245 rd D Y', At(), t—T ,
ALc., 28ZZ-)-
1 3. Approximate date land-disturbing activity will commence: Ni 2, 06 2-01
Monte Day _ Y
i4. Purpose of development(Residential,Commercial, Industrial,etc.): 1. _stcr-1 vt-tl
i5. Approximate acreage of land to be disturbed or uncovered: 0054
6. Total site acreage: 4.40
7. Landowners of record(use blank pages to list additional owners as necessary):
I Owner#1 Name: 1. I'1 AM J '`'` L lc--
1 Address: 2''7 Lew vn ?V V Le 4 f j af A A v . 1 6\J G
I 2 8Z DS
i Telephone: 61y -sic'-3zzS Fax:
Email Address: C.,0V1 vr-i L ( CA//It+.vvi cit.v-etop. LicrytiL
1 Owner#2 Name:
IAddress:
I
I
Telephone: Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed(use blank pages to list
Iadditional deeds or instruments as necessary):
a Book o�y I I Page ?31- • Book Page
i /
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibilit'/Ownership Form
PART B
1. Person(s)or firm(s)financially
1responsible for this land-disturbing activity:
Person or Finn: IDI '\ �1a1 -(+ -
Address: cOrYl m 41w2u.l+t& o i , (kiA-14-b C 12-�ZOS
Telephone: 61, _S20 -322S Fax:
Email Address: CPO-IYu-(-+C G Ga W1 ctakelop. uM'.
2. North Carolina agent for thet- ?ersonnor firm who is financially responsible:
Person or Finn: �ffvl� '3TA.`a-Z.5+'1 ,� �,"
Address: -2-*2-.2 c-o YY1 Y+"UNA N.ec GO.A121 034-6 w 4& (,2 2 S
Telephone: 6 A-Ct—cam' 32.2 Fax:
Email Address: CAS -A-S ( C Y'QL ► ' / • otiN•t(__
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.) 1` IA,.',
Printed Name Title
#�//
Signature / Date
I, U cl_kk, o. 6 0 " cAU-Z (1 ,a Notary Public of the
County of Mede
t l bV ,State of r+A vo`,yA , hereby
certify that O T S personally appeared
before me this day and under oath acknowledged that this fonnn was executed by him/Iter.J Witness my hand an n tari seal,ti 's �Lt ay of .y\e. ,20 Z 4 .
Notary Signature: 1�— titttttt
My Commission expires: 42 0S1 U'L OG0..
..••
r10TA/Zy
Mecklenburg Count} Land Use and Environmental Services Agency =�' •—•— W=
2145 Suttle Ave. "7' PUBLIC) rm'
Charlotte,NC 28208-5237 - .4•• • �a•
Phone[phone] itiOifjF.......•• �4,.•�
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