NCC221971_FRO Submitted_20220526

Town of Huntersville
Tcywn of •
Soil Erosion & Sedimentation Control Ordinance
NORTH CAROLIN 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: Huntersville community Preschool/Daycare
2. Address of land -disturbing activity: 10205 Sam Furr Rd, Huntersville NC 28078
3. Approximate date land -disturbing activity will commence:
0
5
Month Day
Purpose of development (Residential, Commercial, Industrial, etc.): Commercial
Approximate acreage of land to be disturbed or uncovered. 2.68 acres
Total site acreage. 5.034
Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: Tietsort Land Ventures, LLC
Address: 9707 Black Rd, Midland NC 28107
Telephone: [phone]
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone: _
Email Address:
Fax:
Fax:
Year
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary)
Book 35776 Page 888 Book Page
Book Page Book Page
11/19

Financial Responsibility/Ownership Form - Continued
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Persons or Firm: The Montgomery Company LLC
Address: 1919 Augusta Hwy, Lexington SC 29071
Telephone: [phone]
Email Address: [e-mail]
Fax:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: North American Title Insurance Company
Address: 223 S. West Street, Suite 900, Raleigh NC 27603
Telephone
E:I:I:�:1;'II>SLCIY!
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)
Printed Name Title
i'+-, ­�.
Signaturk
Date
a Notary
Public of the County of : _'��� State of S hereby
certify that ��1 c`� �� c c ..~<1 ,;1� s_ ; personally appeared
before me on this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this '� , 4 day of 120 .
Notary Signature:
My Commission Expi
E
ENDA NATOSHA BERRY
Town of Huntersville blic- State of South Carolina
PO Box 664 ommission Expires
105 Gilead Rd., Ste 300arch 16, 2030
Huntersville, NC 28070