NCC216114_FRO Submitted_20211122

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: Latrobe Drive Flex Warehouse and Office
2. Address of land —disturbing activity: 3120 Latrobe Drive, Charlotte NC 28211
3. Approximate date land -disturbing activity will commence: September
Month
4. Purpose of Development (Residential, Commercial, Industrial, etc.)
7 2021
Day Year
Industrial - Warehouse
5. Approximate acreage of land to be disturbed or uncovered: 29-� 1.87 AC
6. List total site acreage: 2.25 Ac
7. Landowners of Record (Use blank page to list additional owners):
Name: Locust Investment LLC
Address: 3120 Latrobe Dr Charlotte, NC 28211
Telephone: [phone]
Fax:
(Area Code) (Area Code)
Email Address:__ -1Pt?,1_-D .�.Jl���.7EE aJ� ►.« , eM
Signature:
Name: �R .4. Vz—k6r.) c—:- aZ
Address:_, 1 Z,b 1...k4 R. U g C JDe,. 22 b
CVI PvRAbJ4 e tJC_ zgu --_
Telephone04 - �Plp`- 24l7— _ Fax:
(Area Code)
(Area Code)
Email Address:
Signatur .
8. Indicate Boo and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 33164 Page
Book Page
ME
Book Page
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: Locust Investment LLC (Fred Wagner)
Address: jMLatrobe Dr Charlotte, NC 29211 _5u&, P_ 'Z 7 0
Telephone: [phone]
(Area Code)
Email Address: [e-mail]
Fax:
(Area Code)
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
(Area Code)
Email Address:
ax:
(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.)
Rr�0 6-.
Printed Nwne
►.� �e �—
Title
:Z -i?- ZOZ
Date
't t/ a Notary Public of the County
of State of lVe i 7t 4 <<rr I ' A hereby
certify that Fr-P Gib es! YI tom' personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this day of T K 20 `� l
Notary Signature: r
My Commission expires: M 41-. c •'`���` w M� '!f r''e
s
CRARLOTTE
ENG NUR1NG A PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://landpermits.charmeck.org
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