NCC231242_FRO Submitted_20230428

Town of• e
FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM Grfral Soil Erosion and Sedimentation Control Ordinance NORTH 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
1. Project name McCord Road Industrial - NCDOT RD Improvements
2. Address of land-disturbing activity(number, street) 11607 McCrod Road
3. Approximate date land-disturbing activity will begin April 30, 2023
4. Purpose of development(Commercial, Residential, Road Improvements
Industrial, etc.)
5. Total acreage of land to be disturbed or uncovered 5.44
6. Total site acreage 45.3
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 1 of Record
Company Name McCord Development LLC Contact Name Anthony Nelson
If applicable
Mailing Address 150 South Fifth Street, Suite 2675, Minneapolis, MN 55402
Physical Address
IfP0 Box listed above
Phone [phone] Email [e-mail]
Landowner 2 of Record
Company Name Contact Name
if applrcah/e
Mailing Address
Physical Address
If PO Box listed above
Phone Email
8. Indicate the Deed Book and Page number the deed or instrument is filed. Attach a list of additional deeds if
applicable.
Deed Book Page Deed Book Page Deed Book Page
36259 358-362
Rev. 8/2022 TOH Staff Reviewer Ownership/Agent: _ Verified at Pre-Con Meeting By: Page 1 of 2

1 �.�nte.n of.
FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM c
Soil Erosion and Sedimentation Control Ordinance NORTH C A R O L I N A
PART B —FRO AND NC REGISTERED AGENT
1. Person(s), firm(s)or Company who is/are financially responsible for this land-disturbing activity.
Financially Responsible Party
Company Name(if applicable) McCord Development LLC Contact Name Anthony Nelson
Mailing Address 150 South Fifth Street, Suite 2675, Minneapolis, MN 55402
Physical Address
If PO Box listed above
Phone [phone] Email [e-mail]
2. If 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 the NC Secretary of State.
North Carolina Agent for Financially Responsible Party
NC Registered Agent Name ARCO Design/Build-Charlotte Contact Name Ross Bridgham
Mailing Address 2100 South Tryon Street, Suite 205 Charlotte, NC 28203
Physical Address
If PO Box listed above
Phone [phone] Email [e-mail]
3. (Optional)Additional contact familiar with the site,who understands the plans,and may represent the company.
Site Contact's Name Ross Bridgham Email [e-mail]
Phone: Office 704-591-4161 Phone: Mobile
PART C — SIGNATURE WITNESSED BY A NOTARY PUBLIC
DO NOT SIGN THIS FORM UNTIL YOU ARE IN THE PRESENCE OF 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 1-�.' t�i O R.1 J'/,• Title or Authority S P
We-Ink Signature i -�C Date `-d)
I, 0I Ali Li CA5PE , a Notary Public of the County of l�O
State of (�-t�l (1D l S , hereby certify that P n fh ni ki LI S personally
appeared before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this ((.19k day of 0 prl l . 20� x
(seal
Official Seal Notary Signature
Cann Casper
Notary Public State of Illinois
My Commission Expires 01/15/2025
My Commission Expires
Rev. 8/2022 Page 2 of 2