NCC233236_FRO Submitted_20231030

Nsuwp
r` Mecklenburg County Soil Erosion and
f ME ` Sedimentation Control Ordinance
Itto 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: Miller Farm Subdivision
2. Address of land-disturbing activity: 13330 Rock Hill-Pineville Rd, Pineville, NC
3. Approximate date land-disturbing activity will commence: January 1 2024
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 92
6. Total site acreage: 113.38
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner#1 Name: DRB Group North Carolina, LLC
Address: 227 W. Trade Street, Suite 400
Charlotte, NC 28202
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner 142 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 37536 Page 596 _ Book Page
Book Page 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: DRB Group North Carolina, LLC
Address: 227 W. Trade Street, Suite 400
Charlotte, NC 28202
Telephone: [phone] Fax:
Email Address: [e-mail]
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.)
Scott Widener Vice President
Prin me Title
i-d72,1f z 7
Signature Date
I, NG'vq G • Cppfe,r , a Notary Public of the
County of 6 asfoc) , State of No(*) Ca rb li & , hereby
certify that kt &D4X 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 2_51" day of Ci2+4bQJ- , 2023 .
Notary Signature: ca
My Commission expires: OjX 12 '21CQ r]
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
NATALIE G COOPER Charlotte,NC 28208-5237
Notary Public-North Carolina I Phone[phone]
4 Gaston County 0
A My Commission Expires Oct 12, 2027