NCC224134_FRO Submitted_20221221

6 R
Mecklenburg County Soil Erosion and
I - ;: : , Sedimentation Control Ordinance
Financial Responsibility/Ownership Form
A O a
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 t 's form with Mecklenburg County Land Use and Environmental
Services. The financially esponsible party will be on record as the party to accept any Notices
of Violation or related d uments for any non-compliance with the above Ordinances. If the
financially responsible pa y 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: ChevaI Lot 113
2. Address of land -disturbing activity: 6017 Long Stirrup Lane, Mint Hill, NC 28227
3. Approximate date Ian disturbing activity will commence: 10 01 2021
Month Day Year
4. Purpose of developme t (Residential, Commercial, Industrial, etc.): SF Residential House
5
7
Approximate acreage df land to be disturbed or uncovered: 0.63
Total site acreage: 0.814
Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: DiPiero Family Trust
Address: 2655 Glenmont Heights Dr.
Canton, OH 44708
Telephone: [phone] Fax:
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 36939 page 334 Book Page
Book Page Book Page
(c tinue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Costner Building Group
Address: 1950 Abbott Street, Ste. 604
Charlotte, NC 28203
Telephone: [phone]
Email Address: [e-mail]
Fax:
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Marshall Andrew Costner
Address: 1950 Abbott Street, Ste. 604
Charlotte, NC 28203
Telephone: [phone]
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 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.)
Marshall Andrew Costner
Printed Name
Signature
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County of U11 i 6`0- , State of
certify that �,'I h;� Llu �� (�'' �GY�j
Chief Executive Officer
Title
A-0 =z
Date
a Notary Public of the
hereby
personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and no anal seah th" day of �+ t � "' , 20 2
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C Mecklenburg County Land Use and Environmental Services Agency
�bl I C 2145 Suttle Ave.
i Charlotte, NC 28208-5237
G ��� Phone [phone]
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