NCC221852_FRO Submitted_20220518

Mecklenburg County Soil Erosion and
fllld J �_,M A
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 rcsporisible,party is out of State, a North, Carolina agent must be assigned,
Please Type or rint
PrQject where land -disturbing activity is to be Ramah Church Flex Space
2. Address of land -disturbing activity:
11928 Rama)' Church Rd, Huntersville NC 28078
3. Approximate date land -disturbing activity will commence:
Month Day Year
4. Purpose of development (Residential, Commercial. Industrial, etc.): commercial/Office -
5e Approxiinateacreage ofland tobedistLirbedor-,,iil(:i),,-ei-ed: 1.10acres
6. Total site acreage: 1.445acres
i. Landowners of record (use blank pages to list additional owners as necessary):
Owner # I Name: Travis Adams Investments, LLC
Address: 16130 Old Statesville Rd, HurAersville NC 28078
Telephone: _20 -®�
J��75�� to —Fax:
Frail Address.._"j°s Zlp 4
Owner #2 Name:
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 33215 -Page 932 Book 04654 Page 788
Book 20802 Page 992 Book Page _
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
Person(s) or firri-i(s) financially responsible for this land-diStUrbing activity:
Person or Firm: Travis Adams Investments, LLC
Address: 16130 Old Statesville Rd, Hunters0le NC 28078
Telephone: 7a '_ 9176'-03 IM — Fax: -20-q- S'7S- 6CI'73
Email Address:
2. North Carolina agent for the person or firm who is financially responsible -
I "erson or Firm:
Address:
Telephone:
Email Address.
-
Fax -
3. The above information is true and correct to the best of nay knowledge and belief and was
provided by me while under oath. (This form must be signed by the Financially responsible
person if ant individual or by an officer, director, partner, aitorney-i n -fact, or other person
with authority to execute instrunwents for the financially responsible company or entity, if not
an Mdividual,)
Printed Name
M=
Titic
EM
k% 1 16 12- 0 -Le,
A c
c"��k a Notary Public of the
County of iiVt State of hereby
certify that
personally appeared
before me this day and under oath acknowledged that this form was executed by him/her,
Witness my hand and not ;al 4,ttiis-,W day of 20 2,C)
11 �Inlrl
Notary Signature.-
-
MI y Commission expires: `�i S'
of %MMKR
Mecklenburg County Land Use and EnvironrnenW Services Aonc 0-4 .411 _
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2145 Stittle Ave.
00;00-Y11.0 V
Charlotte, NC 28208-5237 OUV_ON�
Phone [phone] f Rly P