NCC215335_FRO Submitted_20210928

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Mecklenburg County Soil Erosion and
s
Sedimentation Control Ordinance
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 -disturbing activity is to be undertaken: Lot 1 Tartan Farm
2. Address of land -disturbing activity: 260 Grey Road, Davidson, NC
3. Approximate date land -disturbing activity will commence: July 01 2021
0
5.
on
Month
Purpose of development (Residential, Commercial, Industrial, etC.): Residential
Approximate acreage of land to be disturbed or uncovered: 0.52 Acres
Total site acreage: 2.443 Acres
Day Year
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Damon John Anderson and Brandi Lynn Anderson
Address: PO Box 2350
Davidson, NC 28036
Telephone: [phone]
Fax: N/A
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone:
Email Address:
Fax:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 34356
Book
Form Revised 12-2016
Page 171
Page
Book Page
Book Page
(continue on back or separate pages as necessary)

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Copper Builders LLC
Address: 1235-E East Blvd Unit 155
Charlotte, NC 28203
Telephone: [phone] Fax: N/A
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Wade Miller
Address: 1235-E East Blvd Unit 155PO Box 1292
Charlotte, NC 28203
Telephone: [phone]
Email Address:
Fax: N/A
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.)
David Webb
Printed Name
Vice President
Title
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Date
Lyy' go - �• �� ��'-" , a Notary Public of the
County of �Su , State of ! V V , hereby
certify that I k6 �� �. W-Q t�� personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notariA seal, this , 20I I LJ�4 �
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Notary Signature:
My Commission expires:
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Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte, NC 28208-5237
Phone [phone]
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Notary Public
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