NCC243385_FRO Submitted_20241106

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Mecklenburg County Soil Erosion and
' t Sedimentation Control Ordinance
°R.,-.A,o ,? 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 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: Connery Midfield Station
Lots 2 &4 of Plat 2020114338 and Lot 2 of Plat 2022130054
2. Address of land-disturbing activity: 10825 Boykin Place & 10615 Surrey Green Lane
MATTHEWS NC 28105
3. Approximate date land-disturbing activity will commence: December 29 2023
Month Day Year
4. Purpose of development(Residential, Commercial, Industrial, etc.): RESIDENTIAUCOMMERCIAL
5. Approximate acreage of land to be disturbed or uncovered: 10.90
6. Total site acreage: 34.83
7. Landowners of record (use blank pages to list additional owners as necessary): SEE PAGE 2 FOR
ADDITIONAL LANDOWNERS
Owner#1 Name: 1100 Matthews Mint Hill LLC
Address: 1420 E 7th Street, Suite 150
CHARLOTTE NC 28204
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner#2 Name: MMU PH3 Property Owner LLC
Address: 1420 E 7th Street Suite 150
Charlotte NC 28204
Telephone: [phone] Fax:
Email Address: [e-mail]
8. Indicate Book and Page where the deed or instrument is filed(use blank pages to list
additional deeds or instruments as necessary):
Book 36619 page 900 Book 37649 Page 475
Book 32563 page 296 Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

ADDTIONAL LANDOWNERS OF RECORD
OWNER#3: USCMF BRILEY LP
ADDRESS: 333 WEST WACKER DRIVE, 28TH FLOOR CHICAGO, IL 60606
PAGE 2

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: 1100 Matthews Mint Hill LLC
Address: 1420 E 7th Street, Suite 150
CHARLOTTE, NC 28204
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Wyatt T. Dixon
Address: 1420 E 7th Street, Suite 150
Charlotte, NC 28204
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.)
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Printed ame Title
116023
Signatt(re �� Date
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I, Katie n'1 1 ' i 1 Q s Cran e , a Notary Public of the
County of lk.40 (1 , State of 00(4 )12.r01 i n t� , hereby
certify that Y a D 1 O►'l personally appeared
before me this day and under oath acknowledged that this form wasas executed by him/her.
Witness my hand and notarial seal,this t 11 day of SQ "1 ber ,20 023
Notary Signature: I
My Commission expires: ja-n e des
Mecklenburg County Land Use and Environmental Services Agency
KAREN THIES CRANE 2145 Suttle Ave.
NOTARY PUBLIC Charlotte,NC 28208-5237
Mecklenburg County Phone[phone]
North Carolina
My Commission Expires June 23,2025