NCC241877_FRO Submitted_20240618

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM
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Soil Erosion and Sedimentation Control Ordinance NORTH CA R o L_I v A
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 Olmsted Phase 2C
2. Address of land-disturbing activity (number, street) 12114 Asbury Chapel Road Huntersville NC 28078
3. Approximate date land-disturbing activity will begin May 1 2018
4. Purpose of development (Commercial, Residential, Single Family Residential
Industrial, etc.)
5. Total acreage of land to be disturbed or uncovered 24.60
6. Total site acreage 78.40
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 l of Record
Company Name Pulte Home Company LLC Contact Name Dan Rossi
If applicable
Mailing Address 11121 Carmel Commons Blvd, Charlotte NC 28226
Physical Address
If PO Box listed above
Phone [phone] Email [e-mail]
Landowner 2 of Record
Company Name Contact Name
If applicable
Mailing Address
Physical Address
If PO Box listed above
Phone l 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 Deed Book Page
30581 872
Rev. 8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre-Con Meeting By: Page 1 of 3

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FINANCIAL RESPONSIBILITY OWNERSHIP FRO FORM "lam
Soil Erosion and Sedimentation Control Ordinance NORTH C A R O L I N A
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 Party
Company Name (if applicable) Pulte Home Company Contact Name Dan Rossi
LLC
Mailing Address 11121 Carmel Commons Blvd, Charlotte NC 2822
Physical Address
If PO Box listed above
Phone [phone] Email [e-mail]
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 Contact Name 1
Mailing Address
Physical Address
If PO Box listed above
Phone Email
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 'I IIIS I ORM UNTIL YOL \RI'I IN 1111': 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 signed by 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.
Printed Name i l Vss1 Title or Authority r
Wet-Ink Signature` Date 6 .11-,1 21
I LOUrtn u j') ( , a Notary Public of the County of M cc k(-tnbU r g ,
State of Mph COO011nCA , hereby certify that Dan ROSS 1 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 seR4„0,s 1 ( day of J(.1l , 20 2 4..
;``V:�� NOTAR: : Notary Signature CrtS,kk alLf t.. J
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Rev. 8/2022 "+++U' G GO °� Page 2 of 3