NCC242416_FRO Submitted_20240822

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FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM knteiviI1ew ` •
Soil Erosion and Sedimentation Control Ordinance NORTH A R o l:I N A
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 items on this form must be
filled out accurately and completely.
PART A —PROJECT AND LANDOWNER INFORMATION
1. Project name Cornerstone Baptist Church
2. Address of land-disturbing activity(number, street) 14500 N.C. HWY 73, Huntersville, NC 28078
3. Approximate date land-disturbing activity will begin
4. Purpose of development(Commercial, Residential, Institutional-Church
Industrial, etc.)
5. Total acreage of land to be disturbed or uncovered 4.13
6. Total site acreage 11.95
7. Landowner(s)of Record. The names listed below must match the Deed(s).Attach a list of additional owners, if
applicable.
Note: If the landowner of record is not the person(s)firm(s),or Company'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.
Company Name Cornerstone Baptist Church of Contact Name Brad Boruff
If applicable. Huntersville,Inc
Mailing Address P.O. Box 1643, Huntersville, NC 28070
Physical Address 14500 N.C. HWY 73, Huntersville, NC 28078
UFO Box listed above
Phone [phone] Email [e-mail]
Landoll ner 2 of Record
Company Name Contact Name
If applicable
Mailing Address
Physical Address
If PO Box listed above
Phone Email I
8. Indicate the Deed Book and Page number the deed or instrument is filed. Attach a list of additional deeds if
applicable.
Deed Book Page Deed Book Page Deed Book Page
37663 274
Rev. 8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre-Con Meeting By:_ Page 1 of 3

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FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM l� a
Soil Erosion and Sedimentation Control Ordinance NOR r I i ( ARC)I..I N A
PART B— FRO AND NC REGISTERED AGENT
1. Person(s),firm(s)or Company who is/are financially responsible for this land-disturbing activity.
Financially Responsible Party
Company Name(if applicable) Cornerstone Baptist Contact Name Brad Boruff
Church
Mailing Address P.O. Box 1643, Huntersville, NC 28070
Physical Address 8944 Steinbeck Ct.,Charlotte, NC 28216
UPC,Box listed above
Phone [phone] Email [e-mail]
2. If the Financially Responsible Party listed above does not reside in the state of North Carolina,they must
provide a designated North Carolina agent below. This agent must be registered with the NC Secretary of State.
North Carolina Agent for Financially Responsible Party
NC Registered Agent Name Contact Name
Mailing Address
Physical Address
1fP0 Box listed above
Phone Email
3. (Optional)Additional contact familiar with the site,who understands the plans,and may represent the company.
Site Contact's Name Email
Phone: Office Phone: Mobile
PART C — SIGNATURE WITNESSED BY A NOTARY PUBLIC
DO NOT SIGN THIS FORM UNTIL YOU ARE. IN THE PRESENCE OF A NOTARY PUBLIC
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 information should there be any ch e in the information provided herein.
Printed Name f' ley Zo l.t Title or Authority R i o r
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Wet-Ink Signature 4111P4 1 /'I Date �jZ9,
1 Ta s m yr - Cam !4 j' , tarn Public of the County of L e W r
State of NO i i l l caI'O I�' �/` , hereby certify that gracileeZor-- --- ersonally
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 day of (1 Q]J t , 20 .
• �ss$Ion''•:e�`°•, Notary Signat •
". °TAR Y N i< _
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Rev. 8/2022 9 Page 2 of 3
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FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM
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Soil Erosion and Sedimentation Control Ordinance NORTH CC A R O L.I N A
My Commission Expires 0(0'2 y'ZO 221
Rev. 8/2022 Page 3 of 3