NCC223441_FRO Submitted_20221004

TO�zaf. Town of Huntersville
� 6Ae 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.
Please Type or Print
PART A
1. Project where land -disturbing activity is to be undertaken:
HUNTERSVILLE TOWN CENTER
2. Address of land -disturbing activity: 01711616, 01711617, 01711618, 01711619, 01711627,
01711643, 0171169nn9, 01711625, 0171116126, 01711632, 01711633, 01711634, 01711637, 01711638,
0 71AppCdximate , d e' land-ld18t0urb ng acuity will commence: 01 01 2022
Month Day Year
COMMERICAL AND
4. Purpose of development (Residential, Commercial, Industrial, etc.): RESIDENTIAL
5. Approximate acreage of land to be disturbed or uncovered: 10.1
6. Total site acreage:
9.95
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: NORTH STATE HTC LLC.
Address: 18825 W. CATAWBA AVE. STU 250 CORNELIUS, NC 28031
Telephone: [phone]
Fax:
Email Address: [e-mail]
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 35943 Page 540
Book 34948 Page 39
Book 35641 Page 950
Book Page

Financial Responsibility/Ownership Form - Continued
PART B
Person(s) or firm(s) financially responsible for this land -disturbing activity:
Persons or Firm: NORTH STATE HTC, LLC.
Address: 18825 W. CATAWBA AVE. STU 250 CORNELIUS, NC 28031
Telephone: [phone]
Email Address: jjones(cb-northstatedevelopment.com
Fax:
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 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)
Wm. James Jones
Printed N
Si4nature
Project Manager
Title
11/11/21
Date
I, o"k- tvg V1 t M 6V-)ntA- , a Notary
Public of the County of Irt dLtl State of Nbr n hereby
certify that Wry ` aWs 'T'm„ _ personally appeared
before me on this day and under oath acknowledged that this form was executed by him/her.
Witness my hand
Notary Signature:
My Commission E
Town of Huntersville
PO Box 664
105 Gilead Rd., Ste 300
Huntersville, NC 28070
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