NCC241236_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