NCC233499_FRO Submitted_20231206

4,7 Mecklenburg County Soil Erosion and
ffiEni
Sedimentation Control Ordinance
.r� 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:
LAKE NORMAN HYUNDAI Hy„4nd : o'P OW _
2. Address of land-disturbing activity: 19926 Chartown Dr., Cornelius, NC 28031
3. Approximate date land-disturbing activity will commence: December 1st 2022
Month Day Year
4. Purpose of development(Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 3.0
6. Total site acreage: 5.98
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner#1 Name: TT of Cornelius, Inc
Address: 505 S FLAGLER DR, SUITE 1400, WEST PALM BEACH, FL 33401
Telephone: [phone] Fax: NONE
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 28859 Page 302 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:
t
Person or I. I {fr' Co rvt c i;ttS Zr C
Address: 505 S FLAGLER DR, SUITE 1400 WEST PALM BEACH, FL 33401
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Corporation Service Company
Address: 2626 Glenwood Ave, Ste 550, Raleigh, NC 27608
Telephone: [phone] Fax:
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 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.)
StevC`ferry t'\t-f_ ?rst- f(2'+6
Printed ame Title
08.02.23
I
Signatufe Date
I, _ \'6a.46L VI S1/4-Co . a Notary Public of the
County of PAOr\ r�c`:.h , State of F1cyicio , hereby
certify that �i-Cf._\1Q ) ci_rni personally appeared
before me this day and under oath acknb I •ged that this form was executed by him/her.
Witness my hand and n rial eal, th s 1 ' v day of a�UC--1,1 St , 20 2--- .
Notary Signature: 1 '� L�'! -
My Commission expire G \4- ? 6 __s-_ _ _ _
,1, r..,. Y ETTE M.SHAM
1.:41)
►mwrne ssusrii w�9 nc r HHMecklenburg County Land Use and Environmental Services Agency 1i' ,.
14
2145 Suttle Ave. — —-—— -
Charlotte,NC 28208-5237
Phone[phone]