NCC216572_FRO Submitted_20211123

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: 7�o2fsr C�kE'
2. Address of land —disturbing activity: �i c..35X-4lef cT- 1�.9-2 , CAa014c.oEIF n/C 2822�
3. Approximate date land -disturbing activity will commence: / 2 0 2 cv
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): �2�sia�..f� �✓� c
Approximate acreage of land to be disturbed or uncovered: l A0
List total site acreage: 5• 1.410
Landowners of Record (Use blank page to list additional owners):
Name: viva S-Z>--Jc' �� �..� ►SS Z_&C
Address: v�2Z'S IYGL �o �� �.�.v� /0 0
V'ee-�ws- , n/y �9�2
Telephone: -7oy. 2 ZO Oro Fax:
(Area Code) (Area Code)
Email Address: ��z-rcc• �f+'`�@ Z�M� ��- cm"�
Name:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 3-13 of Page /dg
Book Page
- Continue on Back -
Book Page
Book Page
Revised April 30, 2007

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: S; . 'F C. LC
Address: 32 2 C ^4cG L Eo o �.z , �, Ste, i o o
n.r✓ 99fa /
Telephone: � Y. 2 -Z o -7-G 64- Fax:
(Area Code) (Area Code)
Email Address: t •V-7---C4N£.,— C- (2c,^-r
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: ;�-")€
Address: 29 / S.•-r ., N ,�£� j�,�, v�
CD
Telephone: lay- '2-2-Fax:
(Area Code (Area Code)
Email Address: f �Z7-u Ai-apt"-t � ClcAo4,z. cmA-,
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.)
Printed
Signature
Title
3 9 20
Date
I, n0 �LK::UZ , a Notary Public of the County
Of State of NUEtns C' CLF-Ok ( Vick , hereby
certify that AT_'k m ` -of- tuU . personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notVial seal, this
Notary Signature:
My Commission
day of
•
CHARLOTTE.
ENGINEERING 6 PROPERTY
MANAGEMENT
o,�P
,r P � , F.
2
Szo
op
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpermits.charmeck.org
20
Revised April 30, 2007