NCC220374_FRO Submitted_20220120

Town of Huntersville
Town of •
.Trite e Soil Erosion & Sedimentation Control Ordinance
NORTH CAROLINA Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity as defined in the Town of Huntersville Soil
Erosion and Sedimentation Control Ordinance prior to completing and filing this form with the Town
of Huntersville. The financially responsible party will be on record as the party to receive any
Notices of Violation or related documents related to non-compliance issues with the above
Ordinance. By filing this form, the parties are not relieved from any other permits that may be
required for the Project. 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: Camden Subdivision
2. Address of land -disturbing activity: 13229 McCord Road
3. Approximate date land -disturbing activity will commence: 05 01 2021
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): SF Residential
5. Approximate acreage of land to be disturbed or uncovered: 27.55
6. Total site acreage: 33.442 Acres
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: Salisbury Land Holding, LLC
Address: P.O. Box 2193
Davidson, NC 28036
Telephone: [phone] Fax:
Email Address: jansalisbury@ msn.com
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 24069 Page 862 Book Page
Book Page Book Page

Financial Responsibility/Ownership Form - Continued
Person(s) or firm(s) financially responsible for this land -disturbing activity:
Persons or Firm: Camden Bowman, LLC
Address: 13815 Cinnabar Place
Huntersville, NC 28078
Telephone: [phone] ext. 105
Email Address: [e-mail]
Fax:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Robert Bowman
Address: 13815 Cinnabar Place
Huntersville, NC 28078
Telephone: [phone] ex. 105
Email Address: [e-mail]
Fax:
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 is 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)
Robert Bowman Manager
Printed ame Title
Signature Date
1, Maw 12ft a Notary
Public of the County of _fVkC V I®UY9 , State of N CQMI%nC(- hereby
certify that aoN y+ �,,V Y1-1Ct In personally appeared
before me on this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and ni to ial seal, this1� day of V-Q0V LAI 20 a I
Notary Signature:
My Commission Expires:
P6,R Y� a' P'�
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Town of Huntersville
PO Box 664
105 Gilead Rd., Ste 300
Huntersville, NC 28070