NCC232764_FRO Submitted_20230913

N��pa
r Mecklenburg County Soil Erosion and
YA 1
. l
Sedimentation Control Ordinance
°
¢ Financial Responsibility/Ownership Form
W °qK
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: Nantz Road Retail
2. Address of land-disturbing activity: 18828 W. Catawba Avenue, Cornelius, NC 28031
3. Approximate date land-disturbing activity will commence: 5 1 2023
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 8.30
6. Total site acreage: 6.89
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner#1 Name: Nantz Road Investments, LLC
Address: 2226 State Road 580 Clearwater, FL 33763
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner#2 Name: Evan Walton
Address: 2226 State Road 580 Clearwater, FL 33763
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 36668 Page 32 Book Page
Book 36668 Page 26 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: Nantz Road Investments, LLC
Address: 2226 State Road 580 Clearwater, FL 33763
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: lncorp Services Inc.
Address: 176 Mine Lake Court- Suite 100 Raleigh, NC 27615
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.)
Robert E. Schmidt Jr. Managing Member
Printed Name Title
_w._ 1a
Signature Date
G ,„,./ , a Notary Public of the
County of a etS , State of - r , hereby
certify that ►. '-'', —>A personally appeared
before me this day and under oath acknowledged that this form was executed b ►in�i her.
Witness my hand and not is day , , 20 .
Notary Signature:
PATRICIA M.MCMANUS
My Commission expires: Al !� a:
MY COMMISSION#GG 931879
�� EXPIRES:May 9,2024
''Eovft°P: Bonded Thru Notary Public Undenwritars
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte,NC 28208-5237
Phone[phone]