NCC220404_FRO Submitted_20220120

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 Cite 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 part, 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: CITY PARK Town home phase 5
2. Address of land —disturbing activity:3400 City park Drive, CHARLOTTE, NC
3. Approximate date land -disturbing activity will commence: FEBURARY 01 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): RESIDENTIAL
5. Approximate acreage of land to be disturbed or uncovered: 2.00 AC
6. List total site acreage: 19.37 AC
7. Landowners of Record (Use blank page to list additional owners):
Name: P & L Coliseum LP
Address:3330 Cumberland Blvd, Suite 300 Atlanta GA 30339
Email Address:
Telephone: [phone] Fax:
(Area Code)
c-
[e-mail]
Signat
Name:
Address:
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 20205 Page
Book Page
242
Book Page
Book Page

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: P&L Coliseum Residential Developer LLC
Address:_ 3330 Cumberland Blvd, Suite 300, Atlanta, GA 30339
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: Richard Jersey
Address: 3815 Memorial Parkway, Charlotte, NC 28217
Telephone: [phone]
(Area Code)
Email Address: [e-mail]
Fax:
(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.)
Richard Jersey Manager
Printed Name Title
Signat/er t Date
I, J6 vti o, ✓ Le
Of WC, k4l
certify that
a Notary Public of the County
State of N0 11 C a r n f '>1 cy . hereby
personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
!G�
Witness my hand and notarial seal this 29 day o20 Of
Notary Signature:
My Commission
GI-11 a re4iUar,/ 2 UZ
cIARLorrE_
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
hftp://Iandpermits.channeck.org
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