NCC224025_FRO Submitted_20221206

Town of Huntersville
e
Soil Erosion &Sedimentation Control Ordinance
NORIN 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 forrn 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
[J_13i_1
1. Project where land -disturbing activity is to be undertaken: CYPRESS AT HUNTERSVILLE
2. Address of land -disturbing activity: 13409 OLD STATESVILLE RD. HUNTERSVILLE, NORTH CAROLINA 28078
PID: 01707206 & 01707246
3. Approximate date land -disturbing activity will commence: 2021
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): CONGREGATE HOUSING (CIVIC USE)
5. Approximate acreage of land to be disturbed or uncovered: 5.72 Aces
6. Total site acreage::6.01 AC AFTER ROW DEDICATION
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: JuAN PALACIOS
Address: 13409 OLD STATESVILLE RD. HUNTERSVILLE, NORTH CAROLINA 28207
Telephone:
F�11Ir_T[.Rm
Owner #2 Name:
Address:
Telephone:
Email Address:
Fax:
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 19474 Page 223
Book Page
11/19
Book Page
Book Page

Financial Responsibility/Ownership Form - Continued
PART 6
1, Person(s) or firm(s) financially responsible for this land -disturbing activity:
Persons or Firm: FC HUNTERSVILLE, LLC
Address: 7315 WISCONSIN AVE. SUITE 925W, BETHESDA, MARYLAN❑ 20814
Telephone
[phone]
Email Address: kwoodley®buvermo.com
Fax:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Fidelio Huntersville. LLC
Address: C/o Capitol Corporate Services, Inc.
120 Penmarc Drive, Suite 118, Raleigh, NC 27603
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)
Kevin Woodley
Printed Name
Signature
VP
Title
3 0/22/2020
Date
I fnfl tte LJ f t�ftiS 5 J a Notary
Public of the County of State of M,ir.�' het i hereby
certify that kit IN iC, personally appeared
before me on this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this
Notary Signature:'^ �-
My Commission Expires: /v z_
MATTHEW P CASSO
NOTARY PUBLIC
MONTGOMERY COUNTY
MARYLAND
MY COMMISSION EXPIRES 10.24.2023
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day of -f , k'_r_ 1 20 v�
Town of Huntersville
PO Box 664
105 Gilead Rd., Ste 300
Huntersville, NC 28070