NCC223515_FRO Submitted_20221013

Continue - Financial Responsibility/Ownership Form
•
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: ACTS Retirement Life Communities Inc. , Attn: Chris Herman
Address: 4601 Charlotte Park Drive, Suite 210, Charlotte , NC 28217
Telephone: [phone] Fax:
Email Address: Christopher. [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Stephen Eggles
Address: 4601 Charlotte Park Drive, Suite 210
Charlotte, NC 28217
Telephone: [phone] Fax:
Email Address: [e-mail]
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.)
3 -�'e k' e, V" v C- 9
Printed Na e
I,
Title
VZ z Za Z, Z
Date
^
a Notary Public of the
J
County of �� -Iall ,State of �rcy rc?i �i ,hereby
certify that Ao-, personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial �1, this ' day 4'. Mal-eA , 20 -�Z�
Notary Signature:
My Commission expires:
cj
-2Qz.2)
Mecklenburg County Land Use and Environmental Services A41
2145 Suttle Ave.
Charlotte, NC 28208-5237
Phone [phone]

veH���O c0
i Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
Rr
cFinancial Responsibility/Ownership Form
h AR
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
Matthews Glen Pickleball Courts & Restroom
1. Project where land -disturbing activity is to be undertaken: Building
2. Address of land -disturbing activity:
760 Pavilion View Drive
3. Approximate date land -disturbing activity will commence: July 1 2022
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc,): Amenities and ParMng for Retirement Community
5. Approximate acreage of land to be disturbed or uncovered: 1.5 ac
6. Total site acreage: 56.112 ac
7. Landowners of record (use blank pages to list additional owners as necessary):
OWnPr *1 Nnme' ACTS Retirement Life Communities, Inc.
Address:
420 DELAWARE, DR. FORT WASHINGTON, PA 19034
_ _..
Telephone: [phone]
Fax:
Email Address: Christopher. [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 05652
Book
Form Revised 12-2016
Page 740
age
:..
(continue on back or separate pages as necessary)
Page
Page