NCC231729_FRO Submitted_20230607

NAVRVs.
�a Mecklenburg County Soil Erosion and
1 4 Sedimentation Control Ordinance
1 7. Financial Responsibility/OwnershipForm
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
I. Project where land-disturbing activity is to be undertaken:
Par.4..1 TD t 13go4-ill
2. Address of land-disturbing activity: g311 Artlin tots H;11s Dr. t'k 4 14i11
24221
3. Approximate date land-disturbing activity will commence: Sum 1 ZOZ3
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Zeside:w1qot.1
5. Approximate acreage of land to be disturbed or uncovered: .12 ac-rcS
6. Total site acreage: t. g 0 9
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner#1 Name: Mac%,n S-1-0,..11w or-1- .
Address: is ot9 b Ks t.4- .oloet Gt M:,ni- H;11 WC ZTZ Z 7
Telephone: el o4) G41 - H9 6 I Fax:
Email Address: A.ta{"uZ n a.s i..cLI l w o t`t'l� 6) ti 0-1.o0. c.c.w&
Owner#2 Name:
Address:
Telephone: Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book all le S Page 9 23 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised I2.2016

Continue - Financial Responsibility/Ownership Form
PART B
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1. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: / AR V.ia 5-f r[.o I4-14
Address: 15b j kee,el' bet �f
Ail, - t--ad( , Nc as9,.a7
Telephone: 7i14. 1 'J. lid/&( Fax:
Email Address: lL4 Z�.:CAA41i(„R)nk ) 6:r-hey.. am
2. North Carolina agent for the person or firm who is financially responsible:
Person or Finn: J 1 Z t-T o\I, P)\vAD Rf 1+
Address: (.S'VI
17 O4-3;u c c h[a b ee. C_f'
/V1,AF- i4i1I > �C, asaai
Telephone: 7O-/ to K!. 4'Q 61 Fax: .
Email Address: fiaz'}121/'icnl/-1•-5M/'t,,) R-Hi- �hP�[) . C`�Al
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.)
MpcVj ; 5"f-1 Ite)b f Ow Ne
Printed Name Title
•
� .Q. dI f
�I
Signature Date
I, Q,inGd� • -Dial , a Notary Public of the
County of Mclenhurs , State of /V� , hereby
certify that .71-a.///vpr`.A personally appeared
before me this day and under oath acknowledged that this tbrm was executed by him/her.
Witness my hand and notari. 1, this ay of 4r)riI , 20 a3 .
Notary Signature:
My Commission expires: al/S/o?Da8
DAMEON J DANIEL
Notary Public
Mecklenburg County Land Use and Environmental Service Aghlwklenburg Co.,North Carolina
2145 Suttle Ave. My Commission&&biros Fob,16,2028
Charlotte,NC 28208-5237
Phone[phone]