NCC222570_FRO Submitted_20220725

Town of Huntersville
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Soil Erosion &Sedimentation Control Ordinance
NOFTH 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: Beltway 77
2. Address of land -disturbing activity: 11309 Alexandriana Rd
3. Approximate date land -disturbing activity will commence: 07 18 2022
Month Day
4. Purpose of development (Residential, Commercial, Industrial, etc.): Industrial
5. Approximate acreage of land to be disturbed or uncovered: 75.35 acres
6. Total site acreage: 90.9
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: Beltway 77 Phase I Owner LLC
Address: 280 E. 96th Street, Suite 250, Indianapolis, IN 46240
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone: _
Email Address
Fax:
r ear
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary)
Book 37185 Page 850 Book 37185 Page 855
Book 37185 Page 861 Book 37185 Page 866
11/19

Town of Huntersville
Soil Erosion &Sedimentation Control Ordinance
NORTH CAROL INP 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:
2. Address of land -disturbing activity:
3. Approximate date land -disturbing activity will commence:
Month Day
4. Purpose of development (Residential, Commercial, Industrial, etc.):
5. Approximate acreage of land to be disturbed or uncovered:
6. Total site acreage:
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name:
Address:
Telephone
Email Address:
Owner #2 Name'
Address:
Fax.
Year
Telephone: Fax:
Email Address:
Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary)
Book 37185 Page 871 Book 37185 Page 877
Book 37185 sage 882 Book 37185 Page 889

Town of Huntersville
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��im�ti��f� Erosion & Sedimentation Control Ordinance
2^P°L'"^ 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:
2. Address of land -disturbing activity:
3. Approximate date land -disturbing activity will commence:
4
5
6
7
Month Day
Purpose of development (Residential, Commercial, Industrial, etc.):
Approximate acreage of land to be disturbed or uncovered:
Total site acreage:
Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name:
Address:
Telephone.
Email Address:
Owner #2 Names
Address:
Fax
Year
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 37185 Page 894 Book 37185 Page 897 '
Book 37185 Page 901 Book 37185 Page 904

Trnm of w Town of Huntersville
Soil Erosion & Sedimentation Control Ordinance
NOPTH 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:
2. Address of land -disturbing activity: __
3. Approximate date land -disturbing activity will commence:
4
5
6
7
M.
Month Day
Purpose of development (Residential, Commercial, Industrial, etc.):
Approximate acreage of land to be disturbed or uncovered
Total site acreage:
Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name:
Address:
Telephone: _
Email Address
Owner #2 Name.
Address:
Fax:
Year
Telephone: Fax
Email Address:
Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary)
Book 37185 Page 907 Book 37185 Page 911
Book 37185 Page 915 Book 37185 Page 919

Financial Responsibility/Ownership Form - Continued
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Persons or Firm: Beltway 77 Phase I Owner, LLC
Address: 280 E 96th Street, Suite 250, Indianapolis, IN 46240
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Development and Construction Insight, LLC
Address: 2054 Kildaire Farm Rd, #167, Cary, NC 27518
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 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)
Rich Horn
Printed Name
Authorized Representative
Title
07/14/2022
Signature Date
1, 1)/ng. L. . a Notary
Public of the County of l A2_r 11 �r State of �/1 GL�C� r � t. hereby
certify that 7`Gha.e,0- („ J. ftm-^ personally appeared
before me on this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and not"seal, th s day of J&dt. 20 ZZ
Notary Signature:
My Commission Expires: ©6 116 Z,o Notary Public - Seal
Hamilton County
Commiasian Number NP0727332
My Commission Expires Jun 16, 2028
Town of Huntersville
PO Box 664
105 Gilead Rd., Ste 300
Huntersville, NC 28070