NCC231581_FRO Submitted_20230531

Mecklenburg County Soil Erosion and
i MO
3
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: Serendipity Jetton
19525 Jetton Road Cornelius,NC 2E3031 (Western half of PI0:00512311)
2. Address of land-disturbing activity:
3. Approximate date land-disturbing activity will commence: Feb-April 1 2023
Month Day Year
4. Purpose of development(Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 1.4-acres
6. Total site acreage: 1.38-acres
7. Landowners of record(use blank pages to list additional owners as necessary):
Owner #1 Name: Cornelius Flex Office LLC(a to be formed North Carolina LLC,controlled by Vulcan Property Group)
Address: 4184 Dobys Bridge Road Suite 100 Fort Mill SC 29707
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner#2 Name: Scott Watson
Address: 4184 Dobys Bridge Road Fort Mill SC 29707
Telephone: [phone] Fax:
Email Address: [e-mail]
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary): **Subdivision plat in process**
Book 10626 page 284 Book Page
Book __Page Book Page
(continue on back or separate pages as necessary)
C.....,o-......! 1111114

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: Cornelius Flex Office, LLC
Address: 4184 Dobys Bridge Fort Mill, SC 29707
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: JP Gillmeister
Address: 1750 Camden Road Charlotte NC 28203
Telephone: [phone] Fax:
Email Address: [e-mail]
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.)
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Printed Name Title
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Sign t • date
Le_hco JY l ch.() ie }-- 5 h 4-0 1) f , a Notary Public of the
1 t)County of C �P ( , State of _e21_ [()j.j`f(x _, hereby
certify that 7161-Lii L1 / I i n-e /St ',r personally appeared
before me this day and under oath acknowledged� that this form was executed by him/her.
' 7 Witness my hand and notarial seal, this. day of l� of , .
Notary Signature: k.a! >� C�L
My Commission expires: � 9•�, v. , , "C ' ,,,
Mecklenburg County Land Use and Environmental Services Agency= S 'Z=
2145 Suttle Ave. ;•o\ 4 '-
Charlotte, NC 28208-5237 =L
Phone[phone] OG ' ...
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