NCC231696_FRO Submitted_20230602

Town Of e
FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM c
Soil Erosion and Sedimentation Control Ordinance NORTH C A R O L i 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 rwnleigh Subdivision
2. Address of land-disturbing activity(number, street) 13831 Asbury Chapel
3. Approximate date land-disturbing activity will begin 8/1/2023
4. Purpose of development(Commercial, Residential, Residential
Industrial, etc)
5. Total acreage of land to be disturbed or uncovered 21.67
6. Total site acreage 36.41
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)finn(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.
Landowner 1 of Record
Company Name Shea Homes Carolina, LLC 'Contact.Name JC Champion
If applicable . .
Mailing Address 10130 Perimeter Parkway Suite 300
Physical Address Charlotte NC 28216
If PO Box listed above
Phone [phone] Email [e-mail]
Landowner 2 of Record
Company Name Contact Name
If applicable.
Mailing Address
Physical Address
If PO Box listed above
Phone Email
8. Indicate the Deed Book and Page number the deed or instrument is filed. Attach a list of additional deeds if
applicable.
Deed Book Pa a Deed Book Pa a Deed Book Pa e
38145 189-193
Rev. 8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre-Con Meeting By: Page 1 of 3

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM c4
ie
Soil Erosion and Sedimentation Control Ordinance 1 H�' RO
NORT CAPClI,1N.A
PART B—FRO AND NC REGISTERED AGENT
1. Person(s),firm(s)or Company who is/are financially responsible for this land-disturbing activity.
Financially Responsible Party
Company.Name(if applicable). Shea Homes Carolina, Contact Name . Jay Seymoure
LLC
Mailing Address 10130 Perimeter Parkway Suite 300
Physical Address Charlotte, NC 28216
If PO Box listed above
Phone [phone] :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 Party
NC Registered Agent Name Contact Name.
•. Mailing Address
'::: .Physical Address
If 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 JC Champion Email [e-mail]
Phone: Office Phone:Mobile [phone]
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 t/ Authority� �2�" Title or rr
Wet-Ink Signature ,7->
Dater
I, Sotyoi ( k.e itovis-/ , a Notary Public of the County of Lytcory
State of N0A-1 t CCW mac. , hereby certt6'that 7c..4 wtoufe- 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, thi. #, day of MAC , 20 a 3
\\‘`\G�KAL/rye ii����
IZ
(seal) N- Notary Public J'. /6(//i/ 1
" Lincoln
County Notary Signature
r My Comm. Exp. - ]H -
., 02-14.2028
Rev.8/2022 �' O�iH CAFA50\`C` Page 2 of 3
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FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM c rt Ah7� �
Soil Erosion and Sedimentation Control Ordinance t�` `
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Rev.8/2022 Page 3 o1r3