NCC242123_FRO Submitted_20240715

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Mecklenburg County Soil Erosion a>t�l,
f aINV :` Sedimentation Control Ordinance
. Financial Responsibility/Ownership Form
No person shall initiate any land-disturbing activity covered by Section 6 of the MI cklenburg
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:Chasewood Subdivision
2. Address of land-disturbing activity: 11020 Coble Road, Mint Hill, NC 28227
3. Approximate date land-disturbing activity will commence: July 01 2024
Month Day Year
4. Purpose of development(Residential, Commercial, Industrial,etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 27.40
6. Total site acreage: 91.16 ac I
7. Landowners of record(use blank pages to list additional owners as necessary):
Owner#1 Name: Pinnacle Homes USA, LLC
Address: 2908 Morgan Mill Road, Monroe, NC 28110
Telephone: Fax: _I
Email Address:
Owner#2 Name:
Address:
Telephone: Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed(use blank pages to Li
additional deeds or instruments as necessary):
Book 37201 Page 538 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)

Continue - Financial Responsibility/Ownership Form
PART B
I. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: Pinnacle Home USA, LLC
Address: 2908 Morgan Mill Road, Monroe, NC 28110
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Benjamin Russell
Address: 2908 Morgan Mill Road, Monroe, NC 28110
704 288.7826
Telephone: Fax:
Email Address: [e-mail]
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 financia ly 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.)
Benjamin Russell - Pinnacle Homes USA, LLC President
Printed Name Title
r- .e 1 — i \ c)—e <)-.(f
Signiture Date
€ J S d , a Notary Public of the
County of l)•rN u , State of iti t -' Ccv r , hereby
certify that 1-Li-SS e l t personally appeared
before me this day and under oath acknowledged that this form was executed by hi n/her.
Witness my hand and notarial seal, this � day of Li ( t , 20 D-`( .
Notary Signature: c� 1
My Commission expires: -Z ct a s \\�\\GHENPRF,
Mecklenburg County Land Use and Environmental Services Agency I•1 0 TA R
2145 Suttle Ave.
Charlotte,NC 28208-5237 = PUBLIC
Phone[phone]
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