NCC242820_FRO Submitted_20240913

Town of•
FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORMceir TanteEl
Soil Erosion and Sedimentation Control Ordinance NORTH C A R O L I N 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 Huntersville Lutheran Church
2. Address of land-disturbing activity (number, street) 8000 Mcllwaine Rd
3. Approximate date land-disturbing activity will begin 09-02-2024
4. Purpose of development(Commercial, Residential,
Religious Institution
Industrial, etc.)
5. Total acreage of land to be disturbed or uncovered 3.5 AC
6. Total site acreage 5.17 AC
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 A ent,is re'uired.
Landowner 1 of Record
Company Name Huntersville Lutheran Church Contact Name Douglas Van Sice
(if applicable)
Mailing Address 10928 Heritage Green Dr
City Cornelius State NC Zip 28031
Phone [phone] Email [e-mail]
Landowner 2 of Record
Company Name Contact Name
(if applicable)
Mailing Address
City State Zip
Phone Email
8. Indicate the Deed Book and Page number where the deed or instrument is filed. Attach a list of additional deeds
if applicable.
Deed Book Pa_e OR Deed Book Page PR Deed Book Page
36885 357
Rev.8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre-Con Meeting By: Page 1 of 2

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM
irk ntersf.
Soil Erosion and Sedimentation Control Ordinance NORTH c A R o LI 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) Huntersville Lutheran Church Contact Name Douglas Van Sice
Mailing Address 10928 Heritage Green Dr
City Cornelius State NC Zip 28031
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/on the NC Secretary of
State business re_7ist .
North Carolina Agent for Financially Responsible Party
NC Registered Agent Name Contact Name
Mailing Address
City State Zip
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 THIS FORM UNTIL YOU ARE IN THE 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 OW Ca3 A. g h �• e.. . Title or Authority f $h '
Wet-Ink Signature na,CD Date o?/ 6/2 UZ y
r, Walter L. Harvey, lil , a Notary Public of the County of Mecklenburg ,
State of North Carolina , hereby certify that 1)O'J&L•4 Q. 114., Sic tr 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 seal, this I I. day of S ti P r(v-i'. — , 20' `1 .
( WALTER LL HARVE1,III
•
Notary Public-Northarolina Notary Signature
Mecklenburg Coty
My Commission Expires g 6,2029
— — — — ' — My Commission Expires 08/06/2029
Rev. 8/2022 Page 2 of 2