NCC230092_FRO Submitted_20230112

Town of Huntersville
cN TD"'��ILIC Soil Erosion & Sedimentation Contr eI Ordinance
NORTH CAROLINA Financial Responsibility/Ownerskip Form
No person shall initiate any land -disturbing activity as defined in the Town of Huntersville Soil
Erosion and Sedimentation Control Ordinance prior to complethpq 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:
7448 Cowan Dr. 7448 Venus Ln. 7449 Malabar Rd.
2. Address of land -disturbing activity:
7448 Cowan Dr. 7448 Venus Ln. 7449 Malabar Rd.
lots 1A, 2A, 3A Norman Park
3. Approximate date land -disturbing activity will commence: 12
Month
4. Purpose of development (Residential, Commercial, Industrial, etc.)
01 2022
Da i iYear
Residential
5. Approximate acroago of land to bo disturbed or uncovered: 1.5 acres _
6. Total site acreage. 1.033
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: HABITAT FOR HUMANITY OF THE CHARLOTTE REGION INC
Address: 3816 Latrobe Dr. Charlotte, NC 28211
Telephone: _704-376-2054
Fax: [phone]
Email Address: 0s?'Y1_Q @ Ni ow kA tt0.L) Q_py�
Owner #2 Name:
Address:
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 _35580� Page 54
Book Page
11/19
Book _ Page
Book Page,

Financial Responsibility/Ownership Form - Continued
1. Person(s) or firm(s) financially responsible for this land-disturping activity:
Persons or Firm: Habitat for Humanity of the Charlotte Region
Address: PO Box 220287, Charlotte NC 28222
1 ,
Telephone: [phone] Fax: [phone]
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Cody Shores
Address: PO Box 220287, Charlotte, NC 28222
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 compapy or entity, if not
an individual)
orq
Date
1, ZLZo`h2 W 2,^ , a Notary
Public of the County of t'iri PcLSCn�U2, , State of _ N:, r <il. Ca ny 1—a , hereby
certify that
R- 1
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 J'�T day of 20_Z:L
Notary Signature:
My Commission Expires: �5 ,j 4 06 Z�z3
gET H
;`4v Notary Public 9A
Mecklenburg
County
My Comm. Exp.
�O 08-26-2023
"NmI 11110 ,,o
Town of Huntersville
PO Box 664
10S Gilead Rd., Ste 300
Huntersville, NC 28070