NCC240097_FRO Submitted_20240112

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM c � fp '°f'
Soil Erosion and Sedimentation Control Ordinance �+
NORTH CAROLINA
Instructions: No person shall initiate any land-disturbing activity on one or more acres,as covered in the Town of
Huntersville Soil Erosion and Sedimentation Control Ordinance,before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Huntersville. The Financially
Responsible Party will be on record as the party to accept any Notices of Violation or related documents for any non-
compliance of the Town of Huntersville Soil Erosion and Sedimentation Control Ordinance.If the Financially
Responsible Party resides out of state,a North Carolina agent must be assigned. All items on this form must be
filled out accurately and completely.
PART A—PROJECT AND LANDOWNER INFORMATION
1. Project name Sam Furr Road Multifamily
2. Address of land-disturbing activity(number, street) 10410 Sam Furr Road
3. Approximate date land-disturbing activity will begin 6/19/23
4. Purpose of development(Commercial, Residential,
Industrial, etc.) Commercial
5. Total acreage of land to be disturbed or uncovered 11
6. Total site acreage 10.0311
7. Landowner(s)of Record. The names listed below must match the Deed(s).Attach a list of additional owners, f
applicable.
Note: If the landowner of record is not the person(s)firm(s),or Company's Financially Responsible Party,
as listed in Part B, item 1, a separate Letter of Consent, signed and dated by the Landowner of
Record, or their Authorized A.ent,is re'uired.
Landowner 1 of Record
Company Name Sam Furr Partners Owner, LLC Contact Name
(if applicable) Michael McVickar
Mailing Address 121 W Wacker Dr., Suite 1000
City Chicago State IL Zip 60601
Phone 704_997_8255 Email [e-mail]
Landowner of Record
Company Name Sam Furr Partners O LLC Contact Name
Owner
(if applicable) Shane Seagle
Mailing Address 18825 W Catawba Ave, Ste 250
City Cornelius State NC Zip 28031
Phone [phone] Email [e-mail]
8. Indicate the Deed Book and Page number where the deed or instrument is filed. Attach a list of additional deeds
if applicable.
Deed Book Pa'e al Deed Book Pa a ``
�r5 �,� Deed Book Pa e
37775 567 3
Rev.8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre-Con Meeting By: Page 1 of 2

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM cua fewalie
Soil Erosion and Sedimentation Control Ordinance
NORTH CAROLINA
PART B-FRO AND NC REGISTERED AGENT
1. Person(s), firm(s)or Company who is/are financially responsible for this land-disturbing activity.
Financially Responsible Party
Company Name(if applicable) Sam Furr Partners Owner,LLC Contact Name Shane Seagle
Mailing Address 121 W Wacker Dr., Suite 1000
City Chicago State IL Zip 60601
Phone [phone] Email [e-mail]
2. If the Financially Responsible Party listed above does not reside in the state of North Carolina,they must
provide a designated North Carolina agent below. This agent must be registered with/on the NC Secretary of
State business re•is s .
North Carolina Agent for Financially Responsible Party
NC Registered Agent Name Corporation Service Company Contact Name Shane Seagle
Mailing Address 2626 Glenwood Ave, Suite 550
City Raleigh State NC ZIP 27608
Phone [phone] Email [e-mail]
3. (Optional)Additional contact familiar with the site,who understands the plans,and may represent the company.
Site Contact's Name Wyatt Street Email wstreet@a northstatedevelopment.com
Phone: Office 704-997-8255 Phone: Mobile [phone]
PART C - SIGNATURE WITNESSED BY A NOTARY PUBLIC
DO NOT SIGN THIS FORM UNTIL YOU ARE IN THE PRESENCE OF A NOTARY PUBLIC
The above information is true and correct to the best of my knowledge and belief and was provided by me under oath.
(This form must be signed by the Financially Responsible Person,if an individual,or his attorney-in-fact. If the
Financially Responsible Owner is not an individual,this form must be signed by an officer,director,partner,or
registered agent with the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Printed Name Shane S le Title or Authority Manager
Wet-Ink�Signature
' ,� _li Date '-ll1*l23
l
/, h'``.,' 'Q,htn t ►nV c r Off , a Notary Public of the County of I r& e,1 I ,
State of I V )4 r ,�,,.„Q- , hereby certify that 1(leurl e 6 e13.0 Lz
personally
appeared before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this I'4." day of (-17v1 20 93
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Rev. 8/2022 /*/;�r as�si�iaa�+`C`��0
Page 2 of 2