NCC230337_FRO Submitted_20230207

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM 412elae
Soil Erosion and Sedimentation Control Ordinance NORTH c a ri a L r N .e
Instructions: No person shall initiate any land -disturbing activity on one or more acres, as covered in the Town of
Huntersville Soil Erosion and Sedimentation Control Ordinance, before this forth and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Huntersville. The Financially
Responsible Party will be on record as the party to accept any Notices of Violation or related documents for any non-
compliance of the Town of Huntersville Soil Erosion and Sedimentation Control Ordinance. If the Financially
Responsible Party resides out of state, a North Carolina agent must be assigned. All items on this form must be
filled out accurately and completely.
PART A - PROJECT AND LANDOWNER INFORMATION
Project name
2. Address of land -disturbing activity (number, street)
3. Approximate date land -disturbing activity will begin
4. Purpose of development (Commercial, Residential,
Industrial, etc.)
5. Total acreage of land to be disturbed or uncovered
6. Total site acreage
7
23XI Race Shop
10901 Statesville Road, Huntersville, NC 28078
January 2023
Commercial
10.00
14.77
Landowner (s) of Record. The names listed below must match the Deed(s). Attach a list of additional owners, if
applicable.
Note: Uthe landowner of record is not the person(s) firm(s), or Company's Financially Responsible Party,
as listed in Part B, item 1, a separate Letter of Consent, signed and dated by the Landowner of
Record, or their Authorized Agent, is required.
Company Name 2311 Real Estate Holdings LLC Contact Name i7
I applicable1. �� ChC1t`(�l �. Russel
Mailing Address 2626 Glenwood Ave, Ste 550, Raleigh, NC 27608
Physical Address
If PO Box listed above
Phone Email
Company Name Contact Name
I licable
Mailing Address
Physical Address
.( PD Box listed above
Phone Email
8. Indicate the Deed Book and Page number the deed or instrument is fled. Attach a list of additional deeds if
applicable.
Deed Book Page Deed Book Paize Deed Book Pavo
Rev. $I2022 TOI1 Staff Reviewer Ownership/Agent: Verified at Pre -Can Meeting By: Page 1 of 3

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM I Vli a
Soil Erosion and Sedimentation Control Ordinance NORTH c a s n L N A
PART B - FRO AND NC REGISTERED AGENT
Person(s), firm(s) or Company who is/are financially responsible for this land -disturbing activity
Company Name (if applicable) 12311 Real Estate I Contact Name
Holdings LLC
Mailing Address 12626 Glenwood Ave, Ste 550, Raleigh, NC 27608
Physical Address
PO Box listed above
Phone
Email
2. If the Financially Responsible Parry listed above does not reside in the state of North Carolina, they must
provide a designated North Carolina agent below. This agent must be registered with the NC Secretary of State.
NC Registered Agent Name Contact Name
Mailing Address
Physical Address
I PO Box listed above
Phone Email
(Optional) Additional contact familiar with the site, who understands the plans, and may represent the company.
Site Contact's Name
Phone: Office
Email
Phone: Mobile
PART C - SIGNATURE WITNESSED BY A NOTARY PUBLIC
The above information is true and correct to the best of my knowledge and belief and was provided by me under oath.
(This form must be signed by the Financially Responsible Person, if an individual, or his attorney -in -fact. If the
Financially Responsible Owner is not an individual, this form must be signed by an officer, director, partner, or
registered agent with the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Printed Name Title or thorny e c. r Z 'ct,r
Wet -Ink Signature r,/} Date _ 2 2 a z
a Notary Public of the County of
State of [V hereby certify that ca VV --personally
appeared before me this day and being duly sworn acknowledged that the above farm was executed by him/her.
Witness my hand and notarial seal, this ra
� — day of ]Fbry r✓ v , 20,2.
NorA/? Notary Signature
r"'
o, _
"Es
Rev.
Page 2 of 3

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM
Soil Erosion and Sedimentation Control Ordinance in W-WHIMAN
NORTH CAROLIN
My Commission Expires
Rev. 8/2022
Page 3 of 3