NCC215359_FRO Submitted_20211004

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°s Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
h C;A101 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:
Plantation Estates Expansion PH- 2 Early Grading
2. Address of land -disturbing activity: _
921 Maple Vista CT Matthews NC
3. Approximate date land -disturbing activity will commence: , May 10 2021
51
S
R1
Month
Purpose of development (Residential, Commercial, Industrial, etc.): can"""c y
Approximate acreage of land to be disturbed or uncovered: 5.2
Total site acreage: 43.4
Day Year
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner#1 Name: ACTS RETIREMENT LIFE COMMUNITIES INC.
Address: 420 DELAWARE DR. FORT WASHINGTON, PA 19034
Telephone:
704-845-5900
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone:
Email Address:
Fax:
Fax:
S. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 22972 Page 903
Book 4086 page 694
Book
01,
Page
Page
Forin Revised 12-2016
(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: ACTS RETIREMENT LIFE COMMUNITIES INC.
Address: 733 PLANTATION ESTATES DR. MATTHEWS NC 28105
Telephone:
704-709-2581
Email Address: [e-mail]
Fax:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
Email Address:
Fax:
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.)
Stephen Eggies
Printed Name C%V C I
Vice President Operations Mid -South Region
Title
01 /07/2021
Signature Date
f, (, Uri 0 E C_ U (Y-v (_-f( [ ; __--, a Notary Public of the
�—m
County of ��(, 1 n-� , State of h hereby
certify that( I;-C' personally appeared
before me this day and under oath acknowledged that this form was executed by him/her. 1
Witness my hand an otarial seal, t }s 0 a day of Lji I j oq.1-j, 20 2 [
Notary Signature:
/ L
My Commission expires; Ole /Q Ld_omu
CONNIE COPE CA8TER
Not&fy Public, Nofr Carolina
Mecklenburg County band Use and Environmental Sevices Agency Union Col
2145 Su€€le Ave. My �U#nmissin�= E xpire5
June G7, 202,3
Charlotte, NC 28208-5237
Phone (980) 3 t4-3234