NCC232278_FRO Submitted_20230731

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FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM c
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 Maxwell Avenue Townhomes
2. Address of land-disturbing activity(number, street) 14826 N Old Statesville Rd
3. Approximate date land-disturbing activity will begin 8/15/23
4. Purpose of development(Commercial, Residential, Residential
Industrial, etc.)
5. Total acreage of land to be disturbed or uncovered 3.35
6. Total site acreage 2.72
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 NSR Maxwell, LLC Contact Name Chuck King
If applicable
Mailing Address KssaS la C46a10a, kit Sle ;St Cox-nelcos tG t3 3\
Physical Address
If PO Box listed above
Phone [phone] Email [e-mail]
Landowner 2 of Record
Company Name Contact Name
If applicable
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
38080 961-964
38085 530-532
Rev. 8/2022 TOH Staff Reviewer Ownership/Agent: Verified at Pre-Con Meeting By: Page 1 of 2

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FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM i �jpf( . e
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 fmancially responsible for this land-disturbing activity.
Financially Responsible Party
Company Name(if applicable) NSR Maxwell, LLC Contact Name Chuck King
Mailing Address 1`dl a b w czoa a Si-e. Aso Co rY1e.l t u s NC a.lo31
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 Financialh Responsible Part
NC Registered Agent Name Contact Name
Mailing Address
Physical Address
If PO Box listed above
Phone Email
3. (Optional)Additional contact familiar with the site,who understands the plans,and may represent the company.
Site Contact's Name Chuck King Email [e-mail]
Phone: Office [phone] Phone: Mobile [phone]
PART C SIGNATURE WITNESSED BY A NOTARY PUBLIC
DO NO] SIGN I HIS FORM LN Ill_ YOt ARE IN THE PRESENCE OF A NOTARY PL1BL..IC
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 Chan Se,agl, Title or Authority MoNa5eC I Pekrk r
Wet-Ink Signature y� Date I la b fa3
I, .a`1"�'elrl'i C M S�l of , a Notary Public of the County of Ode II
State of Nor In '( v 7tAiA . , hereby certify that Shotrl e Sod 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 t9 1Q day of ��t [� , 20a 3
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..iNY(seal) 1/23*S O '
NOT° R 9' Notary Sign ture
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Rev. 8/2022 Page 2 of 2