NCC232138_FRO Submitted_20230719

Town of Huntersville
Nuntivon�. e
Soil Erosion & Sedimentation Control Ordinance
NORTH CAROLINA Financial Responsibility/Ownership Form
No person shall initiate any land-disturbing activity as defined in the Town of Huntersville Soil
Erosion and Sedimentation Control Ordinance prior to completing and filing this form with the Town
of Huntersville. The financially responsible party will be on record as the party to receive any
Notices of Violation or related documents related to non-compliance issues with the above
Ordinance. By filing this form, the parties are not relieved from any other permits that may be
required for the Project. 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: Hambright Junction
2. Address of land-disturbing activity: 11209 Statesville Road Huntersville, NC 28078
3. Approximate date land-disturbing activity will commence: 10 01 2021
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 17.0+1-
6. Total site acreage: 22.4+/-
7. Landowners of record (use blank pages to list additional owners as necessary) :
Owner#1 Name: Bi-Part Development, LLC
Address: 18611 Starcreek Drive
Cornelius, NC 28031
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner#2 Name: Jerry L McKenzie and Martha G Roberts (B/W)
Address: P.O. Box 2784
Huntersville, NC 28070
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 35439 Page 489 Book 35439 Page 492
Book 2107 Page 544 Book 36004 Page 615
11/19

Financial Responsibility/Ownership Form - Continued
PART B
1. Person(s) or firm(s)financially responsible for this land-disturbing activity:
Persons or Firm: Blackburn Communities, LLC
Address: 310 Enterprise Drive
Oxford, MS 38655
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Capitol Corporate Services, Inc.
Address: 120 Penmarc Drive, Suite 118
Raleigh, NC 27603
Telephone: [phone] Fax: [phone]
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 is 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)
Jacob Muse Director
Printed Name Title
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Si tf Date
I, VveS'.`/ Doc1dS , a Notary
Public of the County of t-a , State of M•ss :ppc; , hereby
certify that • i ce h personally appeared
before me on this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this �fti day of h6vs�' , 20 a I .
Notary Signature: v au
My Commission Expires: .? / /112-11
Town of Huntersville
PO Box 664 co. tD#219280 C'
105 Gilead Rd.,Ste 300 WESLEY ?ODDS
Huntersville, NC 28070 •.c �4
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.y�..July 19. 2024 . x - .
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