NCC215567_FRO Submitted_20211007

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 fling 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: NORTH HOSKINS PARK
2. Address of land —disturbing activity: 1412 N HOSKINS RD CHARLOTTE NC 28216
3. Approximate date land -disturbing activity will commence:
JUNE 1, 2021
Month
4. Purpose of Development (Residential, Commercial, Industrial, etc.):_
5. Approximate acreage of land to be disturbed or uncovered: 5.5 AC
6. List total site acreage: 8.15
7. Landowners of Record (Use blank page to list additional owners):
Name: SOUTHEAST CHARLOTTE GREEK ORTHODOX PARISH INC
Telephoner
Email Address:
Signature:
Name:
Address: ,
Telephone:
Email Address:
Signature: . . ' '
RESIDENTIAL
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 33659 page 386 Book Page
Book Page
Book Page
Year
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Continue - Financial Responsibility/Ownership Form
PART S
1. Person(s) or firm(s) financially responsible for this land
�-distur ing activity:
Person or Firm: C �7 t4' �1- Q /� J �%
Address: /
Telephone(Area
ax
r%`1) _25�y` (�.-�J�� J� '���-F: i�d�l� 3 �`/' Cl
Code) �Ie
rea Code)
Email Address: Y b 116, P. �ZC /r 'S�l
2. North Carolina agent, for the person or firm who is financially responsible:
Person or
Address:
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
3. The above information is true and correct to the best of nay 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.)
Printed Name i F Title
Signature
Date
I Joyoijod o a Notary Public of the County
of M al<l l,5 81 A9 6 , state of. M 0LTI l ,IU o L, L�\.) tq , hereby
certify that ISU(3EKT -I- personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notar' sal, this. 22day of rt�i2r L 20 2r
Notary signature:
My Commission expires: O / 1
,,,{11111" lip'F"
kQ TKO 1
i� • !,Q„e
ENGINEERING R PROPERTY
MANAGEMENT %I .....
Land Development Division ell,tiFt1t°
600 East Fourth street, Charlotte, North Carolina 28202-2844' s °"`�
Telephone: [phone] Fax: [phone]
http://Iandpennits.charrneek.org
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