NCC242221_FRO Submitted_20240722

0.URo MecklenburgCountySoil Erosion and
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h Sedimentation Control
Ordinance
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+ram 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-disturbingactivityis to be undertaken: Cheval Lot Grading Lot 42
2. Address of land-disturbingactivity: 2408 Salute Blvd., Mint Hill, NC 28227
3 . Approximate date land-disturbing activity will commence: 07 01 2024
pp
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): SF Residential
5. Approximate acreage of land to be disturbed or uncovered: 0.65
6. Total site acreage: 1 .39
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: JOSEPH C THARRINGTON
Address: 1816 Bardstown Road
Charlotte, NC 28226
Telephone: [phone] Fax:
Email Address: Ctharrington @ speedwaymotorsports.com
Owner #2 Name: NICOLE L THARRINGTON
Address: 1816 Bardstown Road
Charlotte, NC 28226
Telephone: [phone] Fax:
Email Address: [e-mail]
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 38350 Page 126 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 firm(s) financially responsible for this land-disturbing activity:
Person or Firm: Built By Coalition, LLC.
Address: 13738 Tynecastle Lane
Matthews, NC 28105
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Daniel Queen
Address: 13738 Tynecastle Lane
Matthews, NC 28105
Telephone: [phone] Fax:
Email Address: [e-mail]
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.)
Daniel Queen Owner
Printed Name Title
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Signature Date
h‘(teijr/L- , a Notary Public of the
County of LAQ13 /LQ4'1 dnt A , State of /L)orJ- V\ j , hereby
certify that 1T3LL&,4r\ personally appeared
before me this day and under oath acknowled ed that this form was executed by him/her.
Witness my hand an o rial seal, this . day of -5_ , 20
Notary Signature: ,Q CyCeC(
My Commission expires: S JUoL7
CO :V ORY ; Z
Mecklenburg County Land Use and Environmental Services Agency •
2145 Suttle Ave. P 'a\> oh
Charlotte, NC 28208-5237 rob'U 5 ti•' J=:
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