NCC216365_FRO Submitted_20211124

. %Mecklenburg County Soil Erosion
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: Asbury Village
7115 ASBURY VILLAGE LN HUNTERSVILLE NC 28078
2, Address of land -disturbing activity;
3. Approximate date land -disturbing activity will commence; C3cteal�er 202
Month Day Year
4. Purpose of development (Residential, Commercial, industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: less than are
6. Total site acreage: 1.145 ages
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner 41 Name: Gregory Perreault
Address: 14765 Caldeford Lane. Huntersville'NC 28078
Telephone: [phone] pax:
Email Address; [e-mail]
Owner 42 Name: axle Perreaul
Address:14765 Caldeford Lane. Huntersville NC 28078
Telephone: [phone]' Fax:
Email Address: [e-mail]
. Indicate Kook and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 69 Page 383 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
F o. m Revised 22-2016

Continue Financial Responsibility/Ownership Fay
PART
1 Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firtn: Gregory Perreadlt
Address: 14765 Caldeford Lane Huntersyille NC 26078
Telephone: [phone]Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Gregory Perreault
Address: 14765 Caldeford' Lane Huntersville NC 28078
Telephone: [phone] Fax:
Email Address: [e-mail]
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.)
Gregory Peppeault Owner
Printed Nan ce _ _-- Title
10/15/2021
Signa e' Date
a Notary public of the
County of ��1 , State of �iN/l ; hereby
t1 certify that WWI& !MMLT personally appeared
before me this day and under oath acknowledged that this form was executed by hi�n�fher.
Witness my hand and notarial seal, this day of NWIIA , 2fr.
Notary Signature: .f
(VOTARY PUBUC
My Commission expires:CDUnIty
North Carofina
�1l �rrarnission xplr�s- . {D�
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte, NC 28208-5237'
Phone [phone]