NCC242309_FRO Submitted_20240816

r i Mecklenburg County Soil Erosion and
'-- • �s' Sedimentation Control Ordinance
.1\ .fl it v
'� ` / 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 foiiu 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: 10701 Clear Creek Commerce
(DMG Glass)
2. Address of land-disturbing activity: 10701 Clear Creek Commerce Drive
Charlotte NC 28227
3. Approximate date land-disturbing activity will commence: September 1 2024
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): r`...,.,--,....+i^1
5. Approximate acreage of land to be disturbed or uncovered: 2.47
6. Total site acreage: 2.503
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner#1 Name: Vintage Land Holdings LLC
Address: 10810 Connell Road
Monroe, NC 28227
Telephone: [phone] Fax:
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 36484 Page 962 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
1. Person(s) or firm(s)financially responsible for this land-disturbing activity:
Person or. Firm: Vintage Land Holdings LLC
Address: 6 a 3 i D.-mod-i- Rd
tvMero-t-. 7I.4;--14 - - -8a-3.-1
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: 3 c .r-r,3.GI „.n
Address: i °S i°° C'c>, ‘-f--iQ -,
M iI
Telephone: [phone] 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 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.)
1
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Printed Name Title 4
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Sina Date 1151
I, / 1 i son 8 H c Cabe , a Notary Public of the
County of nl e c K i Q h b u , State of f D Ca vo i i n aj , hereby i
certify that ( a,X 6 ,h a r personally appeared 1
before me this day d under oath acknowledged that this form was executed by him/her.
Witness my hand .E n• .al.eal, this. i 3 day of J u i L) . 20 Q
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Notary Signature: ,j l A �.J
My Commission expires: M 5 t� o S .N
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Mecklenburg County Land Use and Environmental Serviciaency s
2145 Suttle Ave. s 011 �,
Charlotte,NC 28208-5237 y L C ,
Phone[phone] 1:1 '„ ,•'<V
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