NCC224037_FRO Submitted_20221230

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i Mecklenburg County Soil Erosion and Sedfirllentation
fy o Control Ordinance
°Aa Financial Responsibility/Ownership Form
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 Pint
PART A
1. Project where land -disturbing activity is to be undertaken:
Lor _4 4 :)Ay1DSoN F:7AizmS SL4801VISION
2. Address of land -disturbing activity:
2.1 0 1-7 VAN BRA k E GI Re-c.E
3. Approximate date land -disturbing activity will commence: Au&175T 30 ZDZZ
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 2
6. Total site acreage: .92.
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name:
Address:
Telephone: 70 y - 80? — 6-7 `l 7 Fax:
Email Address: 12 C o rn 5 TPA BLE Cm Pr el I-! o m E S C o rn
Owner 42 Name:
Address:
Telephone: Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book Page Book Page
Boole Page Book Page
(continue on back or separate pages as necessary)
Form Revised 3-3-08

Continue ® Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: M DNTER.Ey (3l4I- L HA RLOTTE , L'LL
Address: 1�3637 IVo2-rHLiNc flRty£ SutTE
Coe-NELt u-s
Telephone: 70 y - Lt3 4- 3$ I D Fax:
Email Address: V;tC-ctssTW0LV aw- Al2HbfAC,S.Goy
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.)
R *i C Pv(-s, &�I-
Printed Name Title
Signature Date
I,
County of
certify that
a Notary Public of the
f bn& . , hereby
personally appeared
before me this day and under oath _acknowledgg}}ed that this form Iwas executed by him/her.
Witness my hand and notarial seal,2 11 this 1 "day of Uc) IV , 20 2 Z
Notary Signature: �,Q �� / w
My Commission expires: 3 - 5
Mecklenburg County Land Use and Environmental Services
700 N. Tryon Street Suite 205
Charlotte, NC 28202-2236
[phone]
FAX [phone]
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