NCC216204_FRO Submitted_20211108

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: Charlotte NC
2. Address of land —disturbing activity: 500 North Sharon Amity Road, Charlotte NC
3. Approximate date land -disturbing activity will commence: November 8 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 4.38 ac
6. List total site acreage: 496 ae
7. Landowners of Record (Use blank page to list additional owners):
Name: Fielding Homes, LLC
Address: 227 W. Trade St., Suite 1610 Charlotte NC 28202
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email 1
Signatr
Name:
Telephone:
(Area Code)
Email Address:
Signature:
Fax:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 36723
Book
Page 143
Page
Book Page
Book Page
Page I

Continue - Financial Responsibility/Ownerships Form
PART
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Fielding Homes, LLC
Address: 227 W. Trade St., Spite 1610, Charlotte C 222
Telephone: [phone]C3 Fax:
(Area Code) (Arre� fie)
Email Address: j actin adrbgrou0.com
2. Forth Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
(Area Code)
Email Address:
LM
(Area Code)
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.)
James Martin
Printed Name
9
Director of Land Development
Title
11f4j2021
Date
a Notary Public of the County
of Lincoln State of. North Carolina hereby
certify that James Martin personally
appeared before me this day and under oath acknowledge that this form ivas executed by him/her.
Witness my hand and notarial seal, this 4"i _ day of November 2021
Notary Signature: ' C A`'°'� `�s1� �i, !A
t�'`„�-
My Commission expires:
Fm
nz IV COO -.0,
fF7
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http-.//Iandpermits,charmeck.org
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