NCC233115_FRO Submitted_20231025

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 Depai tuient,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: 9504 Mallard Creek RD,Charlotte, NC 28262
2. Address of land—disturbing activity: 9504 Mallard Creek RD,Charlotte,NC 28262
3. Approximate date land-disturbing activity will commence: April 1 2023
Month Day Year
4. Purpose of Development(Residential, Commercial, Industrial,etc.): Multi-Family Apartments
5. Approximate acreage of land to be disturbed or uncovered: 11.34 ac
6. List total site acreage: 13.24 ac
7. Landowners of Record (Use blank page to list additional owners):
Name: Universalist Church INC.,Piedmont Unitarian (PIN:04715210, 04715225)
Address: 9704 Mallard Creek RD.
Charlotte, NC 28262
Telephone: C LI -- 5 i 0 — Oc- cam? Fax:
(Area Code) (Area Code)
Email Address: pre..-3,Qcln -Q. p&ac. a F g
Signature: _ '. c.)
f -z- ?.m.y
Name: Joe Brown Strube, Sarah Strube (PIN: 04715215)
Address: 9402 Mallard Creek RD.
Charlotte,NC 28262
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Page I

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: 9504 Mallard Creek RD, Charlotte,NC 28262
2. Address of land—disturbing activity: 9504 Mallard Creek RD, Charlotte,NC 28262
3. Approximate date land-disturbing activity will commence: April 1 2023
Month Day Year
4. Purpose of Development(Residential, Commercial, Industrial, etc.): Multi-Family Apartments
5. Approximate acreage of land to be disturbed or uncovered: 11.34 ac
6. List total site acreage: 13.24 ac
7. Landowners of Record (Use blank page to list additional owners):
Name: Universalist Church INC., Piedmont Unitarian (PIN: 04715210, 04715225)
Address: 9704 Mallard Creek RD.
Charlotte,NC 28262
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name: Joe Brown Strube, Sarah Strube (PIN: 04715215)
Address: 9402 Mallard Creek RD.
Charlotte,NC 28262
Telephone: Fax:
(Area Code) (Area Code)
Email Address: b 5 / 1:. 1�C� /-TT..,,A WT
Signature: l i
Page 1

Continue - Financial Responsibility/Ownership Form
Name: VL Properties. LLC. (PIN: 04715245)
Address: 836 Union ST. S.
Concord,NC 28025
Telephone: q 0 ZI -5( 1 l Fax:
(Area Cod . (Area Code)
Email Address: 1omi v_coocveki V1C. CO m
Signature:
Name: Harold A. E. Smith, Miriam N. Smith(PIN: 04715214,04715246)
Address: 10409 Rockwood RD
Charlotte,NC 28215
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name: Neal. LLC. (PIN: 04715213)
Address: 11035 Golk Links DR.,Unit 78052
Charlotte. NC 28271
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name: Linda Cook Dalton(PIN: 04715212)
Address: 2401 Sharon RD.
Charlotte,NC 28211
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Page

Continue - Financial Responsibility/Ownership Form
Name: VL Properties, LLC. (PIN: 04715245)
Address: 836 Union ST, S.
Concord,NC 28025
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name: Harold A. E. Smith, Miriam N. Smith (PIN:04715214, 04715246)
Address: 10409 Rockwood RD
Charlotte,NC 28215
Telephone: 70 V-30-1/12‘ Fax:
(Area Code) .. ,,,, i _,..,(Area Code)
_4 Email Address: 50 oe-4.1c- '/ 5e:O"dievh of;na,-/,I m--)
Signature: , ,
i —
Name: Neal, LLC. (PIN: 04715213)
Address: 11035 Golk Links DR.,Unit 78052
Charlotte,NC 28271
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name: Linda Cook Dalton (PIN: 04715212)
Address: 2401 Sharon RD.
Charlotte, NC 28211
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name: Tanya D. Caesar-Waller (PIN: 04715211)
Page 2

Continue - Financial Responsibility/Ownership Form
Name: VL Properties, LLC. (PIN: 04715245)
Address: 836 Union ST. S.
Concord,NC 28025
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name: Harold A. E. Smith, Miriam N. Smith (PIN: 04715214, 04715246)
Address: 10409 Rockwood RD
Charlotte,NC 28215
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name: Neal, LLC. (PIN: 04715213)
Address: 11035 Golk Links DR., Unit 78052
Charlotte,NC 28271
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Signature:
Name: Linda Cook Dalton(PIN: 04715212)
Address: 2401 Sharon RD.
Charlotte,NC 28211
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Page 2

Name: 3.inda took Dalton(PIN:
04715212).
Address:_ 2401 shannt
KI>,
C'harluttc,NC 28211
Telephone: 1 o IA (a 6 (v e rj u
Fax:
(Area Code) (Area Code)
Email (efA S Q_t),c_t✓ U° ,;)\ , C o PO
Address: ,11 D1 F;hafDV) FsJo, O, (\41 t ,N C a$'a,+ k
Signature:
<_,T.„.1,
( C)-}-
Name: idea 1).Caesar-Waller(PIN;
047152111
Address:_ 9602 N1allaid( rceI
lia
Charlotte.NC 28262
Telephone:
Fax:
(Area Code) (Area Code)
Email
Address:
Signature:
8. Indicate Book and Page where deed or instrument is filed(Use blank page to list additional deeds or
instruments) Book 07926 Page 598
Book 10517 Page 506
Book 01727 Page .51
Book 29 Page 447
Book, 31792 Page 536
Book 26479 Page 46
Book 3675s Page 29
Book 36231 Page _71.31
Book 30788 Page 217

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
Name: Tanya D. Caesar-Waller (PIN: 04715211)
Address: 9602 Mallard Creek RCS.
Charlotte,NC 28262
Telephone: ( 76 11 ) 7 , cl " 3 IOC Fax:
(Area Code) 7 7, , ,.4'' j 7It ..1
(Area Code)
Email Address: p 0 241`eA i1 t
,C:t ti Wi p i c ., C L/I✓i
aj? g
Signature: Cz, J ._ t, ;/.,
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 07926 Page 598
Book 10517 Page 506
Book 01727 Page 051
Book 33729 Page 447
Book 31792 Page 536
Book 26479 Page 46
Book 36755 Page 329
Book 36231 Page 778
Book 30788 Page 217
Page I

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: Steve Smith. Delray at Mallard Creek,
Address: 715 N. Church St., Suite 110
Charlotte, NC 28202
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
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 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
financiallyncc _ responsiblel company or entity, if not an individual.)
\-e -e ' '• SI k i
Printed Name Title
c.-{zw4A,4 �fib� fCa (20 22
Signature Date
�. 4/Y)efom
-i ies , a Notary Public of the County
, State of Nam,,-IA Cam,1,n A , hereby
of- 1' 4Cklen�w�
ceriifY that Sf eve✓' /i- £M• . personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and not 'al seal, this 614 day of Se?le/►l or , 2022
Notar,t'Signature: .^�- - -
Mv Commission expires: )2-5
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CHARLOTTE_ _ PUBS-`
ENGINEERING&PROPERTY
MANAGEMENT '•;��C` C�•: 41.
'v�C',r'•cFMBE� •'OJ
Land Development Division •.......• ''G
600 East Fourth Telephoner 704 336-6692 Fax:eet,Charlotte, 704/336-6586 Carolina 28202-2844 %,,FNg�1RG...,•`
http://landpermits.charmeck.org