NCC215861_FRO Submitted_20211021

Town of Huntersville
a Soil Erosion & Sedimentation Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity as defined in the Town of Huntersville Soil
Erosion and Sedimentation Control Ordinance prior to completing and filing this form with the Town
of Huntersville. The financially responsible party will be on record as the party to receive any
Notices of Violation or related documents related to non-compliance issues with the above
Ordinance. By filing this form, the parties are not relieved from any other permits that may be
required for the Project. 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:
Thrive Athletics
2. Address of land -disturbing activity: 11031 Mt Holly-Huntersville Rd, Huntersville, NC 28078
3. Approximate date land -disturbing activity will commence: 11 01 2021
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 20.75
6. Total site acreage: 28.87
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: THRIVE PROPERTY HOLDINGS LLC
Address: 16436 MONOCACY BLVD, HUNTERSVILLE, NC 28078
Telephone: [phone] Fax:
Email Address: [e-mail]
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 deeds or instruments as necessary)
Book 36459 page 945 Book Page
Book Page Book Page
11/19

Financial Responsibility/Ownership Form - Continued
PART B
Person(s) or firm(s) financially responsible for this land -disturbing activity:
Persons or Firm: Thrive Athletics, Inc.
Address: 16436 MONOCACY BLVD, HUNTERSVILLE, NC 28078
Telephone:
[phone]
Email Address:
bedwa rds@thriveathletics. net
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 is 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)
Brandon Edwards
Printed Name
Signature
N
President
Title
Date
, a Notary
Public of the County of t� e _, State of DC G!(-01 vk-t, hereby
certify that �C C —'AC") v.�(4S personally appeared
before me on this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and rtotarial seal, this � S�,"" A_rday of 20 ;)
Notary Signature:
My Commission Expires: W C 3
GEORGIANA LASALLE
NOTARY PUBLIC
Town of Huntersville MECKLENBURG COUNTY, NC
PO Box 664 i my camim "EOM j `� S
105 Gilead Rd., Ste 300
Huntersville, NC 28070