NCC222679_FRO Submitted_20220726

Town of Huntersville
41AM16ae Soil Erosion &Sedimentation Control Ordinance
NORTH CAROLINA 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.
PART A
1
Please Type or Print
Project where land -disturbing activity is to be undertaken: Olmsted Phase 2E
2. Address of land -disturbing activity: 9023 Ansley Park Place, Huntersville, NC 28078
3. Approximate date land -disturbing activity will commence: December 1 2020
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Single -Family Residential
5. Approximate acreage of land to be disturbed or uncovered: 17.0
6. Total site acreage: 43.29
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: Pulte Home Company, LLC
Address: 11121 Carmel Commons Blvd, Charlotte, NC 28226
Telephone: [phone] Fax:
Email Address: Jeremy. HuntsmanpPulteGroup.com
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 30581 Page 872 Book Page
Book Page Book Page
11/19

Financial Responsibility/Ownership Form - Continued
PART B
Person(s) or firm(s) financially responsible for this land -disturbing activity:
Persons or Firm: Same as above
Address:
Telephone:
0irEf11_[IrM-M
Fax:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: N/A
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 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)
Jeremy Huntsman
Printed Name
Signature
Director of Land Development
Title
10/26/2020
Date
I, Si ela_ AdgGws , a Notary
Public of the County of � , �� , State of Sx AA Ca,,) L Ea , hereby
certify that
personally appeared
before me on this day Md under oath acknowledged that this form was
executed by him/her.
al� Witness my hand and notarieal, thi ato day of .T&6LO , 20 40
Notary Silt
My Commission Expires:
Sheila Matthews
Town of Huntersville =PUBLIGPO Box 664 105 Gilead Rd., Ste 300 m2029
Huntersville, NC 28070