NCC222031_FRO Submitted (Lot 2)_20220531

,aF Mecklenburg County Soil Erosion and
t
Sedimentation Control Ordinance
• 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: Pleasant Plains Subdivision
-4042 1308 & 4404 Pleasant Plains Rd. Matthews
2. Address of land -disturbing activity:
NC 28105
3. Approximate date land -disturbing activity will commence: 10
th
4.
E
Mon
Purpose of development (Residential, Commercial, Industrial, etc.): Residential
Approximate acreage of land to be disturbed or uncovered:
0.382
6. Total site acreage: 0.423
16 2021
Day Year
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner # 1 Name
Address:
Maria Elena Gonzalez Cabrera
921 Matthews School Rd. Matthews NC 28105
Telephone: [phone]
Email Address:
Owner #2 Name:
Address:
Telephone:
Email Address:
Fax
Fax:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 35892
Page 295
Book Page
Book Page
Book Page
Form Revised 12-2016
(continue on back or separate pages as necessary)

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(or firm(s) financially responsible for this land -disturbing activity:
Person or
Address:
Telephone: -40_`j-, 6 --�9�� Fax:
Email Address:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: —
Email Address:
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 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.)
Printed Name Title
Aa',IM. L Ob— L i- 20 u
Signature Date
1, T. C- V"yW\ V_� , a Notary Public of the
County of O C \fin State of 1Uo-(-4� Ca`'o V r\O, , hereby
E \ �a CwOnz-c l 2 z (abrp fI personally appeared
certify that GV`o��(�G
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this \SA" day of AAc:vAj i- , 20 2 i
Notary Signature-
My Commission expires: Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte, NC 28208-5237
Phone [phone] Q .,