NCC222796_FRO Submitted_20220812

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 party to accept any Notices
o f 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 Male, a North Carolina agent must be assigned. Ail relevant
items on this form must be filled out accurately and completely
Please Type or Print
PART A
1. Projeotl7ameI Furr t Class Cars
. Address of land —disturbing activity: 10209 Albemarle Dead, Charlotte, NC
. Approximate date land-disturbingactivity will commence- July .. _2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.):_ Commercial
. Total acreage of land to be disturbed or uncovered: 1.68 a
. Dist total site acreage: 2.14 a
7. Landowners of record (attach accompanied page to list additional owners). If the landowner of record is not
the person(s) or firms 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:
Tame: Furr Holdings, LL .
Address: PO Box 5647, Charlotte., NC 28299
Telephone: 74-01-1 Fax:
(Area Core) (Area Code)
Email Address:[e-mail]
Name:
Address:
`I'elephoae:
(Area ode)
Email. Address:
Fax:
(Area Code)
. Indicate Boob and Page where deed or instrument is filed Use blank page to list additional deeds or
instruments Bock 3 06 Page
'Book
N' M
11
Book Page
Book Page
Pago 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this lard -disturbing activity Note: If thefinancially nanciaiiy responsible
person(s) on firm(s) has can out-of-.st ie address, a oi,th Carolina agent must be designated in item 2 helow).
Person. or Firm, Farr Holdings, LL .
Address: PBox 5647. Chadoffe, NG 282-99
Telephone-- 4- 01-10 Fax:
area ode) -- -- (AreaCode)
Email Address: brnln.roborl.furr@grnil.o
. 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:
Address:
Telephone:— - Fax:
(Area Code) (Area Code) -
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 fon-o must be signed by the financially responsible person if are individual or by an
officer, director, partner, attorney —in -fact, or other person with authority to execute instruments for the
financially responsible company or enti , if not are individual.)
Printed i
1
Signature Le '
1,
o
certify that
r
Title
Z / -75_ Ir67
Date
a got-gry Public of the County
State of ` 4 her n
�C_r'
appeared before we this day and under oath acknowledge that thisform was executed by hiwhev
WiMess my hand an d notarial seal, this clay o ' 0
Notary Signature:
/_Z-2-/-ZV-1-7
My orram scion expires.' �
•
,l
charlottenc.gov
k Storm later Services — Land Development
604 East Fourth Street, Charlotte, Forth Carolina 2 0 -2 44
Telephone: 704/ - 692
http://charlott n . ovlclevelopmentoenter
Rev, 09;2021
eiso ally
Page

Invoice
Land Development
City of Charlotte
600 East 4th Street
Charlotte, NC 28202
41
C.LOE "
ID r i 1 4 5 Project ID: LD-2019-00 00
Project Marne: Furrst Class Cars
Invoice Date:0711 102
Address: 10209 Albemarle Rd, Charlotte, NC 28227
Fee Item Comments
Grading 1 Erosion Control Permit Per Project
. ....... ..
07/1212022
Amount
$2,260.00
Grading / Erosion Control Permit Per Acre $0.00
Total Fee: $2,260.00
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