NCC220439_FRO Submitted_20220124

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:
Proton Therapy Site (in between Morehead Medical Drive and Kenilworth along E. Morehead Street)
2. Address of land —disturbing activity: 1310 E. Morehead Street
3. Approximate date land -disturbing activity will commence: December 27 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: .2-Fsacres 1.75
6. List total site acreage: 12.986 (dsk)
acres
7. Landowners of Record (Use blank page to list additional owners):
Name: Charlotte Mecklenburg Hospital Authority
Address: P.O. Box 36022
Charlotte, NC 28236
Telephone: Fax:
(Area Code) (Area Code)
Email Address: Av;l Ir10iL� +/�Ptiy�Or+'► ®/4'�YI Km I"F�A �'ir1. Dy'of
Signature:
Name: ftwiyieIGt 1111�INbDl�
Address: IL40 I Arr o w p01 elt Noll • ^
C w 1e-Ite, NG
Telephone: 6 __�g Qq 14 Vi8 :1q 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 7109 Page 477 Book Page
Book Page Book Page
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: Charlotte Mecklenburg Hospital Authority
Address: ^^ ^^ 9401 Arrowpoint Blvd. (dsk)
Ghafla"-, NG 28z3.6.1 Charlotte, NC 28273
Telephone: Fax:
(Area Code)
Email Address: AW
Ylewwvn&
Code)
a KIM
2. North Carolina agent, for the person or firm who is financially responsible:
Person or
Address:
Telephone: Fax:
(Area Code)
Email Address:
(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.)
Ayyia nA AAeAlw bo,- ✓i U 1'Gp_ eyes d en t
Printed Name Title
SA A M CIA O On In/k t P/19 t 9,, [ ° 1-q-1 2-1
Date
VI1\/D� L a Notary Public of the County
of- State of
" ,, � � C , hereby
certify that i�1Mil� �F-VAw�► v personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this _ day of _.�.9n,,, 20 Z 1
Notary Signature:
My Commission expires: �%llf V�'yOTA �r s
G '
eURG CC
ENGINEERING • PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://landpermits.charmeck.org
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