NCC240889_FRO Submitted_20240327

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Mecklenburg County Soil Erosion and
• �17 Sedimentation Control Ordinance
1117' Financial Responsibility/Ownership Form
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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: Brandywine Subdivision: Lot 6
2. Address of land-disturbing activity: 2225 Matthews-Mint Hill Rd
3. Approximate date land-disturbing activity will commence: February 20 2024
Month Day Year
4. Purpose of development(Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 0.41 ac
6. Total site acreage: 0.3781 ac
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner#1 Name: Brian Adams
Address: 10820 Boykin PI, Unit #311
Matthews, NC 28105
Telephone: [phone] Fax: n/a
Email Address: [e-mail]
Owner#2 Name: Nora Adams
Address: 10820 Boykin PI, Unit #311
Matthews, NC 28105
Telephone: [phone] Fax: n/a
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 38444 Page 798 Book _ Page
Book Page Book Page
(continue on back or separate pages as necessary)
Rem 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: Brian Adams
Address: 10820 Boykin PI, Unit #311
Matthews, NC 28105
Telephone: [phone] Fax: n/a
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.)
Brian Adams Land Owner
Printed e Title
I ) I 26 7,\
Signature Date
I, V _ S ew ti.'.e_ , a Notary Public of the
County of , State of I•_\carkl... 1 -rd\i , hereby
certify that aw Pra o.. S 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 4 day of —3—o.A- c..-c.—/ , 20 2 LI .
Notary Signature:
My Commission expires: So.,,,. . 10, 2c'22-
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte,NC 28208-5237 STEPHANIE FOX
Phone[phone] Notary Public,North Carolina
Union County
My Commission Expires
January 10,2028