NCC241832_FRO Submitted_20240617

' trsr Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
rr �•• 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: Q u rd f•,t'l r,
QAmkrio-F-k.t V..CI 2622.4
2. Address of land-disturbing activity: r2D9 efkfaal& B r, 0.-1ALtc ct /
NLC- ! 2''2 2
3. Approximate date land-disturbing activity will commence: Joyi. 06 7-02)-}
Months) 1'av 11l ar j
4. Purpose of development(Residential,Commercial,Industrial,etc.): I �
5. Approximate acreage of land to be disturbed or uncovered: 0; L_} 3
6. Total site acreage: 0,1?
7. Landowners of record(use blank C)pagesgen to list additional owners as necessary):
Owner#1 Name: l r 1 N Ayr V.top✓,nevi,-1- L L C.
Address: 2-'72-1 eethil PY y1 &/t vl ct ke Q k lib d 1.C
82OS
Telephone: 61 — C2-0-3 2 2-S- Fax:
Email Address: CPYlo YGMC4"SC7 C(1,t.GWI de P. l,<?YVL
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 324(14 Page Y31- Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Rcviscd 12-2016

PART B Continue- Financial Responsibility/Ownership Form
1. Person(s)or firn(s)Ifinancially11 __responsible for this land-disturbing activity:
Person or Finn: ,i p�A - - d-4.(+\
Address: 2Aen CAM YY\1411M-Lt l+fn A VV--, (iCMf lA}-I-e 'Kt C i 2- 2,OS
Telephone: 6 1,61 -5 2. 32-2..- Fax:
Email Address: �i^ C.+ l- C.A.vta W1 dI-4-4iop• uM',
2. North Carolina agent forthe Jerson or firm who is financially responsible:
Person or Firm: oLM4 X S t-1
Address: - )-2 C. m w'uy\v1.e,u. 43-A42—l C- 1't011t-tkic Z$ZbS
Telephone: rO A-Ct—S ZO— 3 2.2 Fax:
Email Address: A-S G.-Qvv.Wt •
1 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.)
. 40\iW\ t 0,6 s4-
; Avvvgiv
Printed Name Title
Signature Date
I, U etl e v�CA- 6 0 ►''., I -`-- t/ C1 n ,a Notary Public of the
County of I�l t l�bV State of t- 1_Ailvo`►v•- ,hereby
Icertify that �DTA.:►S1 personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand an n tart seal,tl 's 0Lt ay of J e .20 2 LI .
Notary Signature: obit/1
MyCommission expires: 42 0S 2 l •`‘‘‘G� 4�����``�•
z.kJ: NOTAR j.'
Mecklenburg County Land Use and Environmental Services Agency �i �+
2145 Suttle Ave. P�BOG .
Charlotte,NC 28208-5237 % y•.
Phone[phone] 14;op FNBURG�6��`,
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