NCC230682_FRO Submitted_20230316

Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
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 Print
PART A
1. Project where land -disturbing activity is to be undertaken:
The Forest at Bailey's Glen: Clubhouse
2. Address of land -disturbing activity:
3
4.
18375 Barnhardt Road
Approximate date land -disturbing activity will commence: 03
Month
Purpose of development (Residential, Commercial, Industrial, etc.): commercial
73
5. Approximate acreage of land to be disturbed or uncovered. 6
6. Total site acreage: 8.54
15 2023
Day Ycar
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Forestyle, LLC
Address: 19520 West Catawba Avenue
Cornelius, NC 28031
Telephone: [phone] Fax_ 704-896-2978
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone:
Finail Address:
Fax:
8. Indicate Book and rage where the deed or instrument is bled (use blank pages to list
additional deeds or instruments as necessary):
Book 32639 page 697
:..
Page
M
Page
Page
Form Revised 12-201$
(continue on back or separate pages as necessary)

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Forestyle, LLC
Address: 19520 West Catawba Avenue
Cornelius, NC 28031
Telephone: [phone]
Email Address: [e-mail]
Fax: [phone]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
EM1NO
Telephone:
Email Address:
Fax:
3. The above information is true and correct to the best ol' 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.)
Printed Name Title
Signature
1, at , a Notary Public of the
County of Mec-VIGP3 ioz State of hn��a /ra ' , hereby
certify that j personally appeared
before me this day and under oath acknowledged that this fonn was executed by hirn/her.
Witness my hand and not 'al seal, this c1 r4— day o , 20.
Notary Signs re:t2� • „"•,
My Commission expi
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t
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Fn
Meeklcnburg County Land Use and Enviromnental Services Agency M.
2145 Suttle Ave_ ' a� ���0 6 .
Charlotte, NC 28208-5237 �r • 8 2p2 �G
Phone[phone] �.,,41'OVtjT`I����a`��
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