NCC233090_FRO Submitted_20231016

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 petty 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. All relevant
items on this form must be filled out accurately and completely
Please Type or Print
PART A
1_ Project name: 1-85 Service Distribution Site
_'. Address of land-disturbing activity: Unassigned - Parcel 05553'103
3. Approximate date land-disturbing activity will commence: July 1, 2023
Month DaY Year
4. Purpose of Development(Residential. Commercial. Industrial.etc.): Industrial
5. Total acreage of land to be disturbed or uncovered: 38 acres
6. List total site acreage: 48.92 acres
7. Landowners of Record(attach accompanied page to list additional owners). If the landowner of record is not
the person(s)or finn(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: Beltway 85, LLC
Address: 189 S Orange Ave, Ste 1 110, Orlando, FL 32801
Telephone [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Name: Shane R Hall Revocable Trust
Address:3620 English Garden Rd, Charlotte, NC 28226
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: mflippin(c�mccraneyproperty.com
S. Indicate Book and Page where deed or instrument is filed(Use blank page to list additional deeds or
instruments) Book 37659 Page 93 Book 32085 Page 451
Book Page Book Page

Continue - Financial Responsibility;Ownership Form
PART B
1. Person(s)or firms)financially responsible for this land-disturbing activity(Note:If the financially responsible
person(si or frrtn("si has an our--of-state ad dr•etss,a North Carolina agent must be designated in iron 2 below,:
Person or Firm: Beltway 85, LLC
Address: 189 S Orange Ave, Ste 1170. Orlando, FL 32801
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address. [e-mail]
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: Corporate Creations Network Inc
Address: 15720 Brixham Hill Avenue #300, Charlotte, NC 28277
Telephone:[phone] Fax:
(Area Code) (Area Code)
Email Address: mflippin(CLOccraneyproperty_corn
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 instnnnents for the
financially responsible company or entity,if not an individual.)
Steven ry Apie,Alpir Manager
Printed Name Title
Signature 1,— Date
vV
CAAV \(rOid4 (Ai V 1 . a Natal",Public of the Coma},
o,fV1 con f, ` , State of t OV `(i.(A., hereby
l
certifi �
that � � R� ���,t.1�e�, personally
appeared b ore me this day and under oath actor wledl a that thisform was executedhim/her
.r
pp ef' g 0 by e
Witness my hand and notarial 1, this ,t)' ' dcn,of � �� 2.0
"
Notary Signature:
My Commission expires: 10 I1 J 2-6
111 . . HANNAH JORDAN
• `'� Notary Public
(CO) - Stare of Florida
St,. . Comm#HH321765
!A •\ Expires 10/13/2026
charlottenc.gov
Storni Water Ser ices—Land Development
600 East Fourth Street Charlotte,North Carolina 28202-2244
Telephone 704:;36-6692
http:.Ycharlottenc go:'idevelopmentcenter
Rev,9912031 page?.