NCC233318_FRO Submitted_20231108

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Mecklenburg County Soil Erosion and
ani Sedimentation Control Ordinance
Rrw aARa• 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: McWhirter Road Dental Office
2. Address of land-disturbing activity: The parcel has no current address. The project is located
adjacent to 7844 McWhirter Road, along Fairview Road.
3. Approximate date land-disturbing activity will commence: 06 01 2023
Month Day Year
4. Purpose of development(Residential, Commercial, Industrial, etc.): Commercial - Medical Office
5. Approximate acreage of land to be disturbed or uncovered: 0.90 Acres
6. Total site acreage: 0.88 Acres
7. Landowners of record(use blank pages to list additional owners as necessary):
Owner#1 Name: Baker Real Estate Holdings LLC
Address: 11349 Bain School Road
Charlotte, N.C. 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 37178 Page 380 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
1. Person(s)or firm(s)financially responsible for this land-disturbing activity:
Person or Firm: Fusion General Contractors
Address: 1007 Dornoch Rd. Gastonia NC 28054
Telephone: [phone]
Fax:
Email Address:
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
provided by m (This form e while under oath. and was
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.)
Adam Horowitz
PrintedNirle Manager
4 Title
ems.
Signatime
Date
1, tern-e 1 rr\-e.
a Notary Public of the
County of as-1-0 State of �C
certify that a I hereby
personallybefore me this day and under oath acknowledged that this form was executed byhim/her.appeared
Witness my hand and tarial seal,this yk
Notes Signature: �Y of form,
20 v2�
1Vly Commission expires: C — PAMELA HORNE
GASTON COUNTY,NC
Mecklenburg County Land Use and Environmental Sernces Agency
2145 Suttle Ave.
Charlotte,NC 28208-5237
Phone[phone]