NCC241522_FRO Submitted_20240520

Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
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: Arlington Hills Map 2: Lot 24
2. Address of land-disturbing activity: 8525 Max Meadows Dr
3. Approximate date land-disturbing activity will commence: April 15 2024
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 1 .35 Acres
6. Total site acreage: 4•981 acres
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner 4] Name: BuildNC365, Inc
Address: 3601 White Swan Ct
Indian Trail, NC 28079 •
Telephone: [phone] Fax: Ilia
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 38495 page 558-561 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
I. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: BuiIdNC365, Inc
Address: 3601 White Swan Ct
Indian Trail, NC 28079
Telephone: [phone] Fax: n/a
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Finn:
Address:
Telephone: Fax:
Email Address:
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.)
Yuriy Korniyenko Registered Agent
Printed Name Title
Sp.tgre Date
I, (2`! I CI E-�1 a
, a Notary Public of the
County of , State of , hereby
certify that yc«,' „� .,; . , personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this Th day of )'tokA-C_f\ .e a,!
•
Notary Signature: —'''~ : o`'sr
My Commission expires: 2— U ,;2_0 ` , 01'°"Ry
rn
Mecklenburg County Land Use and Environmental Services Agency'o �C•'`. q- •�� ,����
2145 Suttle Ave. 491-/RC'
Charlotte,NC 28208-5237 ,,,,,,,,,tee,,,,,
Phone[phone]