Loading...
HomeMy WebLinkAboutNCC241236_FRO Submitted_20240422 FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM c '. T • e 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 Oat& C rOQ Ik;t 1 Ptr 1—R-- 2. Address ofland-disturbing activity (number, street) q 30` Lay-V2Y 3. Approximate date land-disturbing activity will begin Mct. 20ZLi 4. Purpose of development (Commercial, Residential, Industrial, etc.) ti dei4- a-1 5. Total acreage of land to be disturbed or uncovered .3 6. Total site acreage LI 5 , l Z 7. Landowner(s)of Record. The names listed below must match the Deed(s).Attach a list of additional owners, if 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 Agent, is required. Landowner 1 of Record Company Name Contact Name Inapplicable, jarkleV PDoW t10.f1,LL C. N r\0. \ Mailing Address 1 l S C:\ r a r Pt c-- 4,80-18 Physical Address If PO Box listed above Phone —4-0 — G — ( i G G' Email y- a.f e. 'F:„0 W mar) 1 d g Landowner 2 of Record Company Name Contact Name Ifapplicable Mailing Address Physical Address jP0 Box listed above Phone Email 8. Indicate the Deed Book and Page number the deed or instrument is filed. Attach a list of additional deeds if applicable. Deed Book Page Deed Book Page 1 Deed Book Page 3%5 '<( 345 I Rev. 8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre-Con Meeting By: Page 1 of 2 T /1. Town do e FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM al 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 Part Company Name (ifapplicable) 0 cL I_cUJ 4-ofn ii,c Contact Name Cpc, co,eny y�Mailing Address s az fscfroc.,jii dq e 0Y6,t., Ciro f(64-4-L , ,'uL a7 3 Physical Address Il PO Box listed above Phone %50 `8Z S 9a 6 a I Email GI COren•}-iy(:-drhoc-F-an.colrt 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 the NC Secretary of State. North Carolina Agent for Financially Responsible Party NC Registered Agent Name Cr-Col, p Contact Name Mailing Address Roo h' iv, LGdker (A- . + 2u�� 'f`J !- > Physical Address If PO Box listed above Phone q/9 K _ Email -q u 4) 111- 0eC40.4tvarkt t9c_ cOm 3. (Optional)Additional contact familiar with the site,who understands the plans,and may represent the company. Site Contact's Name ' Email Phone: Office Phone: Mobile 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 signedby 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. I Printed Name( (`n(elk-VI AU Title or Authority`k�i v‘k S 1 G CI S+aVAw t Yc c,-1-C1 "P eL &(i' r Wet-Ink Signature , , i ei&42&:e°) Date ///;j2c1 I, &i 'li/,� ttk -{-1 u jes , a NotaryPubllii�c ofthe County of EIQS State of lt/o i 1-h Cetk-z/I k1 di , hereby certify (2 that d C/9 Z. Case ki h V1(b 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 1 7 day of (1_,} / , 20 y (seal) p RACHEL MARTIN HAYES Notary Signature QitJJ2 Ot-e1(-- � j'C��� Notary Public,North Carolina Gaston County My Commission Expires May 27,2025 My Commission Expires V a.C� a? a 0a Rev.8/2022 Page 2 of 2