NCC221809_FRO Submitted_20220511

Town of Huntersville
cl�P� e Soil Erosion & Sedimentation Control Ordinance
. i l4 " , L ^ • M IN 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 : „Swo � oe, feL16614C�
0
2 . Address of land-disturbing activity : cm 145
HiAivilti sit-, I 7S
3 . Approximate date land-disturbing activity will commence : 0 / WIZ_
Month Day Year
4 . Purpose of development (Residential , Commercial, Industrial , etc . ) : ?es f�lu4
5 . Approximate acreage of land to be disturbed or uncovered : P. 7.7 � c
6 . Total site acreage: I • 7 (i z az.
7 Landowners of record (use blank pages to list additional owners as necessary)
Own e r # 1 Name : � li �� �d Sivit ':i , ,;;� Si ; s ,4i ,
Address : `7‘ l 8 Reallie ) �in Ms,j/h 73:3476r
lelephone : ?cV( 9 Zq Z C.81 -77 Fax :
Email Address ' U 1 %CS,v ,vtr(4 Mai / • 6521A
Owner #2 Name : JJ1 '€
Ywi c�,
Address : . 04K ?3z& s -rim) Key' thAA.7741 ,.w/ (6 /14' 225.0 ;tr
Telephone : �8 y q 2 9 girl Fax:EmaiIAddress �-�-
8 . Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary)
Book 3 -7ZS? Page Z 'F7 Book Page
Book Page Book Page

Financial Responsibility/Ownership Form - Continued
PART B
1 . Person (s) or firms) financially responsible for this land-disturbing activity-
Persons or Firm : ( //iffal A <IA/
Address : qii ts- &AA, rig .' 11,„: Li c i„,,' A fV( _ZEOX'
Telephone . � �l � Z, Z S" Fax :
Email Address : At -r5 ,A,,
2 . North Carolina agent for the pe on or arm who is financially responsible :
Person or Firm : �V
Address :
Telephone : Fax :
/7
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)
4 /1;4171
i5v1/ 111
Printed Name U� Title
z/./
- /7/0
S I g n a t D e
e 2,4E' , a N o t a ry
Public of the County of 77/(Mq‘olc& / - , State of Ai, , hereby
certify that f;(:) (r ( Sw‘Cd2n7 personally appeared
before me on this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial se this ri day of �'1%� , 20 c.-7 4-7
Notary Signature : �
My Commission Expires/7
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..14 SA Vs
soT,414,
Town of Huntersville
m ' pUE� Li� � U =
PO Box 664 'n t,'�: 2
105 Gilead Rd ., Ste 300 - � , 6er 17 ,ie; `Huntersville, NC 28070 ' ��`'•` � .�� �-pv %.‘•'�