NCC230661_FRO Submitted_20230313

FINANCIAL RESPONSIBILITY OWNERSHIP FRO FORM Aofe
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Soil Erosion and Sedimentation Control Ordinance N o R T x c A R o L I N A
Instructions: No person shall initiate any land -disturbing activity on one or more acres, as covered in the Town of
Huntersville Soil Erosion and Sedimentation Control Ordinance, before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Huntersville. The Financially
Responsible Party will be on record as the party to accept any Notices of Violation or related documents for any non-
compliance of the Town of Huntersville Soil Erosion and Sedimentation Control Ordinance. If the Financially
Responsible Party resides out of state, a North Carolina agent must be assigned. All items on this form must be
filled out accurately and completely.
PART A — PROJECT AND LANDOWNER INFORMATION
L Project name
2. Address of land -disturbing activity (number, street)
3. Approximate date land -disturbing activity will begin
4. Purpose of development (Commercial, Residential,
Industrial, etc.)
5. Total acreage of land to be disturbed or uncovered
6. Total site acreage
SherrillNermillion - Lots 440-449 & 463-467
Holbrooks Road; Huntersville, NC 28078
November 2021
Residential lot development
5.24
5.24
7. Landowner (s) of Record. The names listed below must match the Deed(s). Attach a list of additional owners, if
applicable.
Note: If the landowner of record is not the person(s) firm(s), or Company's Financially Responsible Party,
as listed in Part B, item 1, a separate Letter of Consent, signed and dated by the Landowner of
Record, or their Authorized Agent, is required.
Landowner
Company Name
Contact Name
Pulte Home Company, LLC Dan Rossi
(i applicable)
Mailing Address
11121 Carmel Commons Blvd.; Suite 450
City
Charlotte
State
NC
Zip
28226
Phone
704-430-9392
Email
[e-mail]
Landowner
Company Name
Contact Name
(ifapplicable)
Mailing Address
City
State
Zip
Phone
Email
Indicate the Deed Book and Page number where the deed or instrument is filed. Attach a list of additional deeds
if applicable. —
Rev. 8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre -Con Meeting By: Page 1 of 2

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM cltm eof• e
Soil Erosion and Sedimentation Control Ordinance NORTH CAROL 1 N A
PART B - FRO AND NC REGISTERED AGENT
Person(s), firm(s) or Company who is/are financially responsible for this land -disturbing activity.
Company Name (ifapplicable)
Financially Responsible
Pulte Home Company, LLC Contact Name Dan Rossi
Mailing Address
11121 Carmel Commons Blvd.; Suite 450
City
Charlotte
State
NC
Zip
P8226
Phone
704-430-9392
Email
[e-mail]
It the Financially Responsible Party listed above does not reside in the state of North Carolina, they must
provide a designated North Carolina agent below. This agent must be registered with/on the NC Secretary of
State business reeistrv.
3. (Optional) Additional contact familiar with the site, who understands the plans, and may represent the company.
Site Contact's Name
Email
Vl h4 6- 6 2 v( Y'uv
Phone: Office
Phone: Mobile
_04• 77 3 1-7 3
PART C - SIGNATURE WITNESSED BY A NOTARY PUBLIC
The above information is true and correct to the best of my knowledge and belief and was provided by me under oath.
(This form must be signed by the Financially Responsible Person, if an individual, or his attorney -in -fact. If the
Financially Responsible Owner is not an individual, this form must be signed by an officer, director, partner, or
registered agent with the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Printed Name
Title or Authority V- ?
Wet -Ink Signature) Date �1 :2
I, a Notary Public of the County of
Sta of hereby certify that )Q .,, g, personally
appeared before me this day and being duly sworn acknowledged that the above form was executed by hint/her.
Witness my hand and notarial seal, this 1'b day of _T7
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Rev. 8/2022 �llltttlt�
Page 2 of 2

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