NCC233136_FRO Submitted_20231120

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FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM Tom,of
Soil Erosion and Sedimentation Control Ordinance v o R r H C A R o L t 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 Camden Subdivision - Lots 1 ; 25-41 Individual
2. Address of land-disturbing activity (number, street) 14020 Camden Close Cr
3. Approximate date land-disturbing activity will begin August 2023
4. Purpose of development (Commercial, Residential,
Industrial, etc.) Single-family residential development
5. Total acreage of land to be disturbed or uncovered 6.78 acres
6. Total site acreage 33.02 acres
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 A•ent,is re i uired.
Landowner 1 of Record
Company Name Contact Name
(if applicable) Camden Bowman Robert Bowman
Mailing Address 13815 Cinnabar PI
City Huntersville State NC Zip 28078
Phone [phone] Email [e-mail]
Landowner 2 of Record
Company Name Contact Name
(if applicable)
Mailing Address
City State Zip
Phone Email
8. Indicate the Deed Book and Page number where the deed or instrument is filed. Attach a list of additional deeds
if applicable.
Deed Book Page Deed Book Page Deed Book Page
36330 93-97
Rev. 8/2022 TON Staff Reviewer Ownership/Agent: Verified at Pre-Con Meeting By: Page 1 of 2

FINANCIAL RESPONSIBILITY OWNERSHIP (FRO) FORM Town of
Control OrdinanceNORTH
i. �
Soil Erosion and SedimentationCo o O d �o r:•r H CA rz o rti r a n
PART B - FRO AND NC REGISTERED AGENT
1. Person(s), finn(s)or Company who is/are financially responsible for this land-disturbing activity.
Financially Responsible Party
Company Name(if applicable) Pufte Home Company, LLC Contact Name Dan Rossi
Mailing Address 11121 Carmel Commons Blvd.; Suite 450
City Charlotte State NC Zip 28226
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/on the NC Secretary of
State business re,is .
North Carolina Agent for Financially Responsible Party
NC Registered Agent Name Contact Name'.
Mailing Address
City State Zip
Phone Email
3. (Optional) Additional contact familiar with the site,who understands the plans, and may represent the company.
Site Contact's Name Email
Phone: Office Phone: Mobile
PART C - SIGNATURE WITNESSED BY A NOTARY PUBLIC
DO NOT SIGN THIS FORM UNTIL YOU ARE IN THE PRESENCE OF A NOTARY PUBLIC
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 1Va.vu �t Title or Authority \i 2
Wet-Ink Signatur — Date Q kt-1/4:93
I, '(S(p,, j-j' , a Notary Public of the County of MPcV_.LQ_r1 ,
State of a� Co (t'- V , hereby certif'that t , . .oSS.r �Jpersonally
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 ( 1-. day of w✓LcU , 202.. .
(seal) c
x��•�� Porsha Stewart
r a NOTARY PUBLIC Notary Signature -el1/4A-A4*
. j )1
.��+..� Mecklenburg County,NC
My Commission Expires May 09,2028
My Commission Expires PINCuO CP i 2O'2
Rev. 8/2022 Page 2 of 2