NCC233110_FRO Submitted_20231024

A• . Mecklenburg County Soil Erosion and
`' Sedimentation Control Ordinance
47 .0 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:
8317 MAX MEADOWS DR, CHARLOTTE, NC 28227
2. Address of land-disturbing activity:
8317 MAX MEADOWS DR, CHARLOTTE, NC 28227
3. Approximate date land-disturbing activity will commence: 07 01 2023
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): RESIDENTIAL
5. Approximate acreage of land to be disturbed or uncovered: 0.788
6. Total site acreage: 1.20
7. Landowners of record(use blank pages to list additional owners as necessary):
Owner#1 Name: PDX CONSTRUCTION, LLC
Address: 5411 MINEWOOD AVENUE
MINT HILL, NC 28227
Telephone: [phone] Fax:
Email Address: [e-mail]
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 37449 Page 991 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
I. Person(s) or lirm(s) financially responsible for this land-disturhing activity:
Person or Firm: PDX CONSTRUCTION, LLC
Address: 5411 MINEWOOD AVENUE
MINT HILL, NC 28227
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax:
Email Address:
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 indk idual or by an officer. director, partner. attorney-in-fact. or other person
ith authority to execute instruments for the financially responsible company or entity. if not
an individual.)
Aleksandr Adzhigirey PRESIDENT
Printed Nam• Dille •
L' 85-/zy23
Sign.nurL Date i
1. n,„ . a Notary Public of the
County of 1 1 1 Q( IC\-f) 0( ( . State of M. CCv(O\i (ZC . hereby
�� R 1e\endf Zk; oCei , appeared
end
certify that �X 6-0-cur 4;(] ! b� �� c�anali} appeared
before me this day and under oath acknowledged that this form was executed by himiher.
Witness in) hand and nota ' l seal, this (-LT.. day of
Notary Signature: AV_11E ?� aP �ssl0we, l�
}- p 1�( K)6vemheY 7o?T - _ t °01ARy���;
M Commission zx fires: _ ,
Mecklenburg County land Ilse and Environmental Services Agency';�( '
2145 Sutte Ave. '1/,'''BURGC.I
Charlotte.NC 28208-5237
Phone[phone]