NCC222933_FRO Submitted_20220816

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Mecklenburg County Soil Erosion and
F Sedimentation Control Ordinance
Financial Responsibility/Ownership Form
H CP
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: The Venue
2. Address of land -disturbing activity: 19813 S. Main St
3.
4.
S.
6.
Approximate date land -disturbing activity will commence: January
Month
Purpose of development (Residential, Commercial, Industrial, etc.): medl�c
Approximate acreage of land to be disturbed or uncovered: 2.13
Total site acreage: 2.07
01 2022
Day Year
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner#1 Name: Cornelius Mixed Use Investors, LLC
Address: 2400 South Blvd
Charlotte, NC 28203
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone:
Email Address:
Fax:
8. Indicate Book and Page where the dced or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 36647 page 216 Book Page
Book 36647 page 98 Book Page
(continue on back or separate pages as necessary)
Fonn Revised 12-2016

Continue -- Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Cornelius Mixed Use, LLC
Address: 2400 South Blvd Ste 300
Telephone: [phone] Fax:
Email Address:
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.)
George Macon Partner
Printeolftme , ,� Title
11.15.21
Signature (/ Date
1, 7Fa,6� At A U_00-w , a Notary Public of the
County of _)Aec.1 c&ab^g , State of p In► CAVtLQ (A "A hereby
certify that 6Eo personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this l '5 41` day of __J DveV ►S.e_ , 20 Z i
Notary Signature:
My Commission expires: 0 j _9_1
r_'[ T E] 1 A,
MOTAR1,
Mecklenburg County Land Use and Environmental SeMces Age
2145 Suttle Ave. 01 PUB
1 C r
Charlotte, NC 28208-5237
Phone [phone]