NCC201254_New FRO demonstrating plan transfer_20210422

N13URO
c Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
Rr o� a cpR Financial Responsibility/Ownership Form
N
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 : Mint Hill , NC
Brighton Park Subdivision , at the intersection of Soaring Eagle Ln & Phyliss Ln
2 . Address of land- disturbing activity : 6011 Phyliss Ln ( Parcel 13527529) & ( Parcel 13527183)
3 . Approximate date land-disturbing activity will commence : 04 16 2020
Month Day Year
4 . Purpose of development (Residential , Commercial , Industrial , etc . ) : Residential
5 . Approximate acreage of land to be disturbed or uncovered : 1 , 96
6 . Total site acreage : 2 . 218
7 . Landowners of record (use blank pages to list additional owners as necessary) ,
Owner # 1 Name : Meeting Street Towns LLC
Address : 19925 Jane Crump Lane
Cornelius NC , 28031
Telephone : 704 - 714 - 3077 Fax :
Email Address : royjt ') meetingstreet . net
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
ideeds or instruments as necessary) ,
Boole 9+ 4 )
9 d Page � I Boole Page
Boole Page Book Page
(continue on back or separate pages as necessary)
Fonn 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 : PlaceCrafters LLC
Address : 19925 Jane Crump Lane
Cornelius NC , 28031
Telephone : 704 - 714 - 3077 Fax :
Email Address : royjt9meetingstreet . net
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 . )
Printed Name Title
� Z
Signature Date/
I , � �✓ � 'J � � u `S`S U , a Notary Public of the
County of / /(-�� I�11 �/LtJ� � State of / I a t 1' r 611 %'2 C(, , hereby
certify that �(Ss � �ZJLU U V personally appeared
before me this day and under oath acknowledged that this form was executed by him/her .
Witness my hand an tarial seal , this day of �� , 20 Ad
Notary Signature :
My Commission expires :
C
Mecklenburg County Land Use and Environmental Service AgencyLISA J DELBUSSO
2145 Suttle Ave . NOTARY PUBLIC
Charlotte , NC 2820 &5237 Gaston County
Phone (980 ) 314-3234 North Carolina