NCC223153_FRO Submitted_20220908

T, Town of Town of Huntersville
Soil Erosion & Sedimentation Control Ordinance
NIC) R T If CA TfO 1, IN A 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: Silver Gilead LLC Reese Blvd East
2. Address of land -disturbing activity: Reese Boulevard East
3. Approximate date land -disturbing activity will commence:
06 01 2022
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Industrial/Office
5. Approximate acreage of land to be disturbed or uncovered: 2.5 acres
6. Total site acreage: 4.57 acres
7. Landowners of record (use blank pages to list additional owners as necessary)
Owner #1 Name: Silver Gilead LLC
Address: 1805 Sardis Road North, Ste 120
Charlotte, NC 28270
Te!ephone: 704-364-8881 Fax: [phone]
Email Address: [e-mail]
Owner #2 Name:
Address:
Telephone:
Email Address:
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 35398 Page 447 Book Page
Book Page Book Page
11/19

Financial Responsibility/Ownership Form - Continued
Person(s) or firm(s) financially responsible for this land -disturbing activity:
Persons or Firm: Silver Gilead LLC
Address: 1805 Sardis Road North, Ste 120
Charlotte, NC 28270
Telephone: [phone]
Fax: [phone]
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
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)
Mil up Silver
Printed N 3 Title U
Signature D9te I
I, N\ � L.% �-'> (-, C" ­T�. �' (2, U 6 , a Notary
Public of the County of LkD�\INC— State of �Lt � hereby
certify that �_ 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 day of _VYN ca 20 c_>_2 Q
Notary Signature:
My Commission Expires:
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Town of Huntersville
PO Box 664
105 Gilead Rd., Ste 300
Huntersville, NC 28070