NCC216670_FRO Submitted_20211201

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4 V Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
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z ,a GpFinancial Responsibility/Ownership Form
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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: Gutman Residence
2. Address of land -disturbing activity:
8925 Brief Road, Mint Hill, NC
3. Approximate date land -disturbing activity will commence: October 15 2021
Month Day
4. Purpose of development (Residential, Commercial, Industrial, etC.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 0.99
6. Total site acreage: 4.00
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Neil Gutman
Address: 1007 Emerson Lane
Indian Trail, NC 28079
Telephone:
512-800-9981
Email Address: [e-mail]
Owner #2 Name: Darlene Gutman
Address: 1007 Emerson Lane
Indian Trail, NC 28079
Fax:
Telephone: [phone] Fax:
Email Address: [e-mail]
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 35446
Page 343
Page
Book Page
Book Page
Year
Fonn Revised 12-2016
(continue on back or separate pages as necessary)

Continue - Financial Responsibility/Ownership Form
F7515W'-
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Emerald Point Realty and Construction
Address: 1209 Skyway Drive
Monroe, NC 28110
Telephone:
704-737-7393
Fax:
Email Address: [e-mail]
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.)
W- I L q vct-rnM
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Date
1, '-6 eA-VA CA VY�A T Wb I e , a Notary Public of the
County of eoc�u, t-r, State of N�o',:• A(\ l _� V-ClJl a , hereby
certify that N ei I "'I V:�hCt VX personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notariaj seal, this -i day of Y 1 , 20 '2- l
Notary Signature:
E
My Commission expires: lqy J A,' -I"%
MY COMM EXP.
Mecklenburg County Land Use and Environmental Services Agency 02/17/2025 ; U
2145 Suttle Ave. t'
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Charlotte, NC 28208-5237 ; F ' •...... '
Phone [phone]