NCC221226_FRO Submitted_20220331

Town of Huntersville
e 11
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Soil Erosion &Sedimentation Control Ordinance
N0RTH C A R 0 L r N A 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:
Bonnie Cone Leadership Academy
2. Address of land -disturbing activity:
16101 Poplar Tent Church Road Huntersville, NC 28078
3. Approximate date land -disturbing activity will commence: November
Month
4. Purpose of development (Residential, Commercial, Industrial, etc.):
5. Approximate acreage of land to be disturbed or uncovered:
6. Total site acreage: ± 37.03 Acres
15 2021
Day Year
Institutional
± 29.8 Acres
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: Fairhaven LLC
Address: 12601 East US HWY 60 Gold Canyon, AZ 85118
Telephone: H000 - 71y9 • _117r'22 Fax:
Email Address: Te f!Lz!� 0 1 win/1 I. Gom
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 28297 Page 174 Book Page
Book Page Book Page
11/19

Financial Responsibility/Ownership Form - Continued
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Persons or Firm: BOLA Huntersville, LLC
Address: �71 lGJ L',2YI L4K t 5+e `3�
a Vf LOLkG G'" Vr (q)L4I zj
Telephone: (6o I . ow - "00 Fax:
Email Address: 4� G S61nt01 dWGtL
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:__ Rena j S+zy'ea AAe44M I Vic,
Address: D d VVfn-tea� VbcecA
F-a, I eig) h, N C. IyIk7m
Telephone: 14 - yco - H Fax:
Email Address:
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)
Printed a Title
0/'&/l�2+
Signature Date
I, a-%V?,Adtjp, \Aj j' lSOYt _ , a Notary
Public of the County of �- -� L� , State of (�Ltw" ,hereby
certify that �1Z4t^- personally appeared
before me on this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and !, his r day of , 20
Notary Signature:
My Commission
OrNotary
JACQUELfNE WIL50NTQWn of IiUntersVllle Public - State of UtahComm. No, 710579
PO Box 664 MY Commission Expires on Feb 14, 2024
105 Gilead Rd., Ste 300
Huntersville, NC 28070