NCC231775_FRO Submitted_20230608

N eUR0
�v G
Mecklenburg County Soil Erosion and
. .).4,.?�` ` Sedimentation Control Ordinance
Q� l vaP Financial Responsibility/Ownership Form
co,
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: Wallace-Carter Residence
15241 June Washam Rd., Davidson, NC 28036
2. Address of land-disturbing activity:
3. Approximate date land-disturbing activity will commence: March 15 2023
Month Day Year
4. Purpose of development (Residential, Commercial,Industrial, etc.): Residential Single Family Home
5. Approximate acreage of land to be disturbed or uncovered: 2.0 ac
6. Total site acreage: 10.34 ac
7. Landowners of record(use blank pages to list additional owners as necessary):
Owner#1 Name: William Darrell Wallace Jr.
Address: 4300 Gail Ln., Concord, NC 28027
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner#2 Name: Amanda Wallace
Address: 4300 Gail Ln., Concord, NC 28027
Telephone: [phone] Fax:
Email Address: [e-mail]
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 537 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: Gerrard Builders, LLC
Address: 1920 Abbott Street, Suite 302
Charlotte, NC 28203
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Gerrard Builders, LLC
Address: 1920 Abbott Street, Suite 302
Charlotte, NC 28203
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 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.)
Bryan Gerrard ,,,,,� iAM" <<,
President
Printed Name Title AX\J ", . (10,s,'�.
zts
_ 2/13/2023`►3% �e T9,�, s;
,3-
Signature / Date 0T� �(� � � m
I,
_J O7 TT a Notary Public oft oUto,'
County of / �6d� , State of G , hereby
certify that ��C.r1 i� �� personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal is / say of ��! , 20 ��
Notary Signature: /71 �=
My Commission expires: 6 zoz6
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte,NC 28208-5237
Phone [phone]