NCC242779_FRO Submitted_20240912

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Mecklenburg County Soil Erosion and
w M Sn Control
Financial Responsibitationlity/OwnershipOrdinance Form
N C„
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
Cheval Lot Grading Lot 65
1. Project where land-disturbing activity is to be undertaken:
3728 Piaffe Ave., Mint Hill, NC 28227
2. Address of land-disturbing activity:
3. Approximate date land-disturbing activity will commence: 08 01 2024
Month Day Year
4. Purpose of development(Residential, Commercial, Industrial, etc.): SF Residential House
5. Approximate acreage of land to be disturbed or uncovered: 0.874
1.003
6. Total site acreage:
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner#1 Name: Anastasi John Roupas
Address: 3904 Fawn Hill Rd, Matthews, NC 28105
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner#2 Name: Donna Kay Roupas
Address: 3904 Fawn Hill Rd, Matthews, NC 28105
Telephone: Fax:
Email Address: DrouPa.S50A GMPrtL•COM
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 37648 Page 646 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: Built By Coalition, LLC.
Address: 13738 Tynecastle Lane
Matthews, NC 28105
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Daniel Queen
Address: 13738 Tynecastle Lane
Matthews, NC 28105
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.)
Daniel Queen President
Printed Name Title
—7/Z/Zc{
Signature Date
I, 7 �• � � , a Notary Public of the
County of in eel 1 0A , State of lerrikA `i(O )>— , hereby
certifythat � �t'n,e_A � .� personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this Z day of U.11 , 20 2y
Notary Signature:
My Commission expires: B 20?� \,\```\\ 1SIHA// /4,
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Mecklenburg County Land Use and Environmental Services Agency = uotV
2145 Suttle Ave. COmm.Exp
Charlotte,NC 28208-5237 M 02-p6-2°2a
Phone[phone] ��''.,20