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HomeMy WebLinkAboutNCC231597_FRO Submitted_20230526 NeuRo °$ Mecklenburg County Soil Erosion and 2 Sedimentation Control Ordinance ? �?P „ �- , Financial Responsibility/Ownership Form 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 this form with Mecklenburg County Land Use and Environmental Services. The financially responsible party will be on record as the party to accept any Notices of Violation or related documents for any non-compliance with the above Ordinances. 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: Sedona Farms - Lot 3 2. Address of land disturbing activity: 15037 June Washam Rd. Davidson NC 28036 3. Approximate date land-disturbing activity will commence: June 30 2022 Month Day Year 4. Purpose of development (Residential, Commercial, Industrial, etc.): Residential 5. Approximate acreage of land to be disturbed or uncovered: 2.95 AC 6. Total site acreage: 10.26 AC 7. Landowners of record(use blank pages to list additional owners as necessary): Owner#1 Name: Kurian & Joyce Koshy Address: P.O. Box 2424, Cornelius, NC 28031 Telephone: 978-660-4343 Fax: Email Address: skoshy165@a gmail.com 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 36700 page 600 Book Page Book Page Book Page (continue 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: Kurian &_Joyce Kosh,y Address: P.O. Box 2424, Cornelius, NC 28031 Telephone: 978-660-4343 Fax: Email Address: skoshy165@gmail.com 2. North Carolina agent for the person or firm who is financially responsible: Person or Firm: Address: Telephone: Fax: Email Address: 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.) KAY'\ 0-v\ 1(0.--- \/\\( 0 Li,v\-e_ r Printed Name Title /(,,' �--� �� �/ Si nature g Date 1, W cndY Srn/ , a Notary Public of the 6-‘a, /L County of efo , State of nor*1 t!'flurnlf 116, , hereby certify that /1 LL!"IQ n kos hi personally appeared before me this day and under oath acknowledged that this form was executed by him/her. Witness my hand and notarial seal, this a/ day of U-.pri 1 ,20 a . Notary Signature: a \ J 1 p My Commission expires: L/a / Q cQ WAndy Smith NOTARY PUBLIC Gaston County North Carolina Mecklenburg County Land Use and Environmental Services Agenrlly Commission Expires 9126/2026 2145 Suttle Ave. Charlotte,NC 28208-5237 Phone(980)314-3234