NCC215936_FRO Submitted_20211115

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Chapter 17, Article 2 of the Charlotte City Code or
Section 6 of the Mecklenburg County Sedimentation and Erosion Control Ordinance prior to completing and filing this
form with the City of Charlotte Engineering and Property Management Department, Land Development Services Division
or Mecklenburg County Land Development Services. The financial responsibility party will be on record as the party to
accept any Notices of Violation or related documents for any non-compliance of the City of Charlotte Soil Erosion and
Sedimentation Ordinance_ 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: 3441 South Apartments
L. Address of land —disturbing activity: 3423 - 3441 South Boulevard, Charlotte, NC 28209 &
111 Hollis Road, Charlotte, NC 28209
3. Approximate date land -disturbing activity will conunencc: January 1 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial I Multi -Family
5. Approximate acreage of land to be disturbed or uncovered: 3.21 AC
6. List total site acreage: 2.70 AC
7. Landowners of Record (Use blank page to list additional owners):
Name: Ralph Lee Hembree
Address: 2300 Monticello Dr
Gastonia, NC 28056
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name'
Robert Clay Sparrow
Address: 18341 Royal Oaks Road
Charlotte, NC 28278
Telephone:
(Area Code)
Email Address:
Signature:
8. indicate Book and Page whet
instruments) Book 26487
Fax:
(Area Code)
for insXament is filed (Use blank page to list additional deeds or
Page 426 Book Page
Book 07603 Page 311
Book Page
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Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: KA LOSO Holdings LLC
Address: 307 W. Tremont Ave., Suite 200
Charlotte, NC 28203
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: douten(a_akridge.com
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
(Area Code)
Email Address:
Fax:
(Area Code)
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.)
Printed Name / Title}oZt2�'Y�
Signature Date
I, N A fik an:.e,t CC -Of M D A a Notary Public of'the e-> .
Of ( o l L'M W6, . State of . hereby
certify that If 4-84 C-00 &L, personally
appeared before me this day and under oath acknowledge that this form was executed by hirWher.
Witness my hand and notarial seal, thi . S� dayyf /hr3 L►S t . 20 2 t
Notary Signature:
My Commission expires.
NE Cq
•�• .
9-14-24
OF C�A�
zRIV--4tr- 194, ?_ 0 2 L(
NOTARY PUBUC D1smicT o (1i14U
My CwaiWm Expires September A 2024
CHARLOITE
MGME MNG k PROPERTY
MAMAGMEWT
Land Development Division
600 Fast Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:[phone] Fax:[phone]
http://landpermits.charmeck.org
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