NCC241181_FRO Submitted_20240418

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4t~ +r Mecklenburg County Soil Erosion and
p Sedimentation Control Ordinance
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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.
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- Please Type or Print
PART A ��jj ,�I ,,
1. Project where land-disturbing activity is to be undertaken: 53 i q eclr�l,� ✓1 Q r,
- Arty-14-e C 2 z2-
2. Address of land-disturbing activity: 5 3 t -I ei4 r t�,�►n i'/ i f p-,-'e
Nc- , 262 2.i
3. Approximate date land-disturbing activity will commence: ?n L 1 U -20).1
• 4. Purpose of development(Residential,Commercial,Industrial,etc.): esl(�Q yrtic
5. Approximate acreage of land to be disturbed or uncovered:_Qi 3 5 ,(-eS
0 6. Total site acreage: 0,6?3
1 7. Landowners of record(use blank pages to list additional owners as necessar
y):
i
Owner#1 Name: 0.0 n A 61 ye- 0 .t 1-4G
I Address: 2 "Zq 061rnOY1 V11-e 0 I. ti Y`2 01)Q 1 wT
232os N�
Telephone: q - �j 2{}-322 - Fax:
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Email Address: 0 is 0 Gu Oa rn d e ve1 o �flyvt
Owner#2 Name:
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Address:
h i
1
1
,
Telephone:
Fax: .!
Email Address: i;
8. Indicate Book and Page where the deed or instrument is filed(use blank pages to list ,
additional deeds or instruments as necessary): '
Book 3_1�1I Page S34
Book Book Page
__Page Book
Page
(continue on back or separate pages as necessary)
Form Revued 12-2016

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Continue-Financial Responsibility/Ownership Form
PART B
1. Person(s)or finn(s)financially`_ r sponsible for this land-disturbing activity:
Person or Firm: -10 h u `j S-i
Address: Z/Z WI pylwea ( a rep 11/4)C
28201
Telephone: 6 V 1 - 52 0- 3Z2 5 Fax:
.ti Email Address: CO v‘Ara Cts a C CkY AA)Y de .top.( Wt.
'':1 2. North Carolina agent for the person or firm who is financially responsible:
•
Person or Firm: ..1 O A A ((l 1<:+
`4 Address:24)1 fAmcrnonve (A l lVC
Telephone: 64 q - JS 0 —3ZZ 5 . Fax:
Email Address:
la. 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
s;; 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.)
1 40110 14-CA OS q 61,14 al&V-
Printed N. . Al Title
I, ..y. — o�l����zi
si, ;.! , Date
I, Valk-N ili*° Z v PAS,.,- �� ,a Notary Public of the
County of eL 1�_t Q✓)bey w�_ ,State of�1�V�'�'V (-CA CV 11 AAC\ ,hereby
certify that �OI� Nl I t'� �S G `dl S .. personally appeared
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before me this day and under oath acknowledged that this form was executed by him/her. t 1 1
Witness my hand o/ seal, (5 of Apr L ,20 Z-T
Notary Signature:/l.!'4- x( U.(U U-V-1 ����tt i i i►iiri�
2 • /' C
My Commission expires: 12 )O s g - ;4. '.
Mecklenburg County Land Use and Environmental Services Agepejt4 , PUBt.C m
2145 Suttle Ave. ,, ',''
Charlotte,NC 28208-5237 ..fC,t:1••,,,,,,••'"icy`
Phone[phone] 1i10RTNBUR�C(j\�•
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