NCC230862_FRO Submitted_20230328

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM i,of o e
Soil Erosion and Sedimentation Control Ordinance N O R T H C A R o t r N A
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 form 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
1. 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
Hambright Forest
7112 Hambright Road
01/15/23
Residential
6.27 Ac.
11.80 Ac.
7. Landowner (s) of Record. The names listed below must match the Deed(s). Attach a list of additional owners, if
applicable.
Note: If the 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.
Landownerof Record
Company Name
Michael Kucera Contact Name Michael Kucera
If applicable
Mailing Address
6308 Gold Wagon Ln. Charlotte NC 28227
Physical Address
6308 Gold Wagon Ln. Charlotte NC 28227
If PO Box listed above
Phone
Email
Landownerof
Record
Company Name
Contact Nam e
I applicable
Mailing Address
Physical Address
If PO Box listed above
Phone
Email
Indicate the Deed Book and Page number the deed or instrument is filed. Attach a list of additional deeds if
applicable.
Deed Book Page P _ f Deed Book
25419 434
Deed Book
Rev. 8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre -Con Meeting By: Page 1 of 2

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM
Soil Erosion and Sedimentation Control Ordinance
PART B - FRO AND NC REGISTERED AGENT
e af. e
NORTH CAROLINA
Person(s), firm(s) or Company who is/are financially responsible for this land -disturbing activity.
Financially Responsible Party
Company Name (if applicable)
Knotts Development Contact Name Michael Knotts
Mailing Address
P. O. Box 687 Pineville NC 28134
Physical Address
11510 N. Community House Rd.#150, Char.28277
If PO Box listed above
Phone
7045425486
Email
[e-mail]
2. If the Financially Responsible Party 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.
North Carolina Agent for Financially Responsible
NC Registered Agent Name Contact Name
Mailing Address
Physical Address
1 PO Box listed above
Phone Email
3. (Optional) Additional contact familiar with the site, who understands the plans, and may represent the company.
Site Contact's Name I IEmail
Phone: Office I I Phone: Mobile
PART C - SIGNATURE WITNESSED BY A NOTARY PUBLIC
DO NOT SIGN THIS FORM UNTIL YOU ARE IN THE PRESENCE OF 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
Wet -Ink Signature
e—
State of G
Title or Authority 're 5 i-e,Y1,1
Date ll,13dl.29
a Notary Public of the County of /1iGa-+'—es
hereby hereby certify that IN :Coe 1 410 0 personally
appeared before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 3o day of tPVL-At-beT , 20 2-—
►`J �al) 'QiON.IPA
Notary Signature
CU
My Commission Expires
Rev. 8/2022
Page 2 of 2

To: Town of Huntersville
Re: Hambright Forest
Parcel #01517102
I am the owner of record on the above referenced property,
And I herein consent to designate Knotts Development
To be the financial responsible party and submit plans for
permitting & development process and approvals for this
parcel.
Date: ? ,6" 3 1 21,0.12,
Michael Kucera