NCC222171_FRO Submitted_20220613

City of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity on one or more acres as covered by Chapter 17 of the Charlotte
City Code of Ordinances before this form and an acceptable erosion and sedimentation control plan have been completed
and approved by the City of Charlotte. The financially responsible party will be on record as the pt any Notices
of Violation or related documents for any non-compliance of the City of Charlotte Soil Erosion andeSedimentation
Ordinance. If the financially responsible party is out of State, a North Carolina agent must be assigned. All relevant
items on this form must be filled out accurately and completely
PART A Please Type or Print
1. Project name: 227 Southside Drive
2. Address of land —disturbing activity: 227 Southside Dr. Charlotte, NC 28217
3. Approximate date land -disturbing activity will commence: February 1 2022
4. Purpose of Development Residential Commercial, Industrial, etc.):
p ( Commercial onth Year
5. Total acreage of land to be disturbed or uncovered: 2.45 Acres
6. List total site acreage:3.99 Acres
7. Landowners of Record (attach accompanied page to list additional owners). If the landowner of record is not
the person(s) or firm(s) financially responsible as listed in Part B, item 1, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
Name: 227 Southside Owner LLC
Address: 411 West Putnam AvP i'ramnlAllfl . r,r AC-OnA
Telephone: [phone] Fax:
I-- r_ I..
Email Address:
com (Area Code)
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
Instruments) Book 35497
page 647
Book
Page
Book
Page
Book
Page
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1- Person(s) or firm(s) financially responsible for this land -disturbing activity(Note: If the financially responsible
Person(s) or firms) has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: 227 SouthSide Owner LLC
Address: 411 West Pi t!tnam Aw.
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: edeppoliti(&acrarnnmi i .com
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina agent:
Person or Firm: Todd Latour
Address: 300 W Summit Avenue Suite
200 Charlotte NC 28203
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: Todd.Latourno colliere - m
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.)
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Printed Name
Title
Signature
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of State of
a Notary Public of the County
_ � y �% certifyhereby
that C. �f ; S,�- f .��
appeared before me this day and under oath acknowledge that this form was executed by him/her. ersonally
Witness my hand and notari
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chariottenc.gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
Rev. 09/2021
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