NCC241739_FRO Submitted_20240609

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Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
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�Aa s 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:
BAPS Mandir Charlotte (PIN: 21509402, 21509403, 21509406)
2. Address of land-disturbing activity:
2021 Independence Commerce Drive
3. Approximate date land-disturbing activity will commence: August 1 2021
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Institutional
5. Approximate acreage of land to be disturbed or uncovered: 15.43
6. Total site acreage: 17.37
7. Landowners of record(use blank pages to list additional owners as necessary):
Owner#1 Name: BAPS Charlotte, LLC
Address: 81 Suttons Ln., Piscataway, NJ 08854
Telephone: [phone] Fax:
Email Address:
Owner#2 Name: BAPS Charlotte, LLC
Address: 4100 Margaret Wallace Rd., Matthews, NC 28104
Telephone: [phone] 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 33067 Page 621 Book 34062 Page 320
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: Nik Patel / BAPS Charlotte, LLC
Address: 4100 Margaret Wallace Rd., Matthews, NC 28104
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
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.)
t- PcdreA ( W v.Z r
Printed Name Title
3/c2-`1/2-
Signature Date
Yo?lhul / / , a Notary Public of the
County of 40641A , State of NC , hereby
certify that egjef personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and otari seal, this day of jtfi2 lit , 20 2I .
Notary Signature:
My Commission r s: 0 7 2
YAGNESH D PATEL
it;Notary Public, North CarolhgM klenburg County Land Use and Environmental Services Agency
*:idl/. Ra dole County 2145 Suttle Ave.
e` `f; My Co mi s n fires
Charlotte,NC 28208-5237
Phone[phone]