NCC220434_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: Clark Village Townhomes
2. Address of land -disturbing activity: 912 West Rocky Road, Charlotte, NC 28213
3. Approximate date Land -disturbing activity will commence: July 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential - Multifamily
5. Approximate acreage of land to be disturbed or uncovered: 20.05 Ac
6. List total site acreage: 24.62 Ac
7. Landowners of Record (Use blank page to list additional owners):
Name: John Isaac Clark Jr.
Address:_ 224 Robinlynn Road, Matthews, NC 28105
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Signature:
Name: Nest Communities, LLC (David Hughes)
Address: PO Box 3965, Mooresville, NC 28117
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: dhughesAnesthomes.com
Signature:
S. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 01482 Page
119
Book 26178 page 596
Book Page
Book Page
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Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Nest Communities, LLC (Contact: David Hughes)
Address: PO Box 3965, Mooresville, NC 28117
Telephone: [phone] Fax:
(Area Code)
Email Address: [e-mail]
(Area Code)
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
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.)
I� UfrM+r=S
Printed Name
Signature
Title
- Z - I f
Date
I• Q 04,13 a Notary Public of the County
of State State of_ (/YTr"66Y hereby
certify that _lii.Gvi ei personally
appeared before me this day and under oath acknowledge that thisF�fon was executed by him/her.
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Witness my hand and notarialseal, this o2 day of 4K-e iC 20
Notary Signature:
My Commission expires:�
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NOTARY PUBuC
Well CourttyR NO
My Commbft Expires ,funs 22, 2M
CHARLOTTE_
ENGINEERING 6 PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iancipemiits.charmeck.org
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