NCC220536_FRO Submitted_20220207

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: GENERATIONS AT SHALOM PARK
2. Address of land —disturbing activity: 4913 PROVIDENCE ROAD CHARLOTTE, NC 28226
3. Approximate date land -disturbing activity will commence:
MAY 1, 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): INSTITUTIONAL
5. Approximate acreage of land to be disturbed or uncovered:
6. List total site acreage: 11.02
11.5 AC
7. Landowners of Record (Use blank page to Iist additional owners):
Name: Temple Israel Inc
S: 4901 Providence Rd Charlotte, NC 28226
Telephone:
(Area Code)
Email Address:
Signature:
Name: Foundation of Shalom Paris Inc
Fax:
Address: 5007 Providence Rd Suite 102 Charlotte, NC 28226
Telephone:
(Area Code)
Email Address:
(Area Code)
foundation of
shalom park
signature
ax:
(Area Cod) ,
rA
. or
Signature:
S. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 8876 . Page 773 Book 13453 Page 663
Book 8119 Page 821
Book 8653 page 726
Page 1

Additional Deeds
Indicate Book and Page where deed or instrument is filed
Book 10348 Page 903
Book10740 Page 772
Book 10707 Page 589
Book 10410 Page 299
Book 10410 Page 296
Book 32119 Page 660
Book 4496 Page 858

Continue - Financial Responsibility/Ownership Farm
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Aldersgate at Shalom Park, Inc.
Address: 3800 Shamrock Dr Charlotte NC 282
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:
david signed as a
property owner
for temple israel
a Code)
(Area Code)
3. he above information is true and correct to the best of my knowledge and belief wid was provided by me
bile under oath. (This form must be signed by the financially responsible person if an individual or by an
cer, director, partner, attorney -in -fact, or other person with authority to execu instruments for the
ancially responsible company or entity, if not an individual.)
Printed Name Title 6PAf0 OF rpOn9C�
ti
I, L[ u 4 .- 10.n inn n c I a
of . n4' V 10 A,-J - - State of rA r��6 r_'a'::4U n"
certify that
appeared before me this day and under oath acknowledge that this form was executed by
Witness my hand and notarial seal, this � k day of
Notary Signature:
My Commission expires:
'1 i i M11M
Ina
OJARY
a
PUBVCP
�
�F �NBURGG■'' `
r7yr�flHmpply�l���
ENGMEENNG & PROPERTY
MAMiAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax:[phone]
http:j/iandperrnits.charmeck.org
-t 1 ,rAwW, V9 Z tJZ-1
Date
atary Public of the County
, hereby
personally
er.
20 Qj
Pale 2

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Aldersgate at Shalom Park, Inc.
Address: 3800 Shamrock Dr Charlotte NC 28215
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:
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
white 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.)
Vr_ k A 61�P si�CNT
Prin Name Title
I
ign a Dati
MAU4' of
of jVVCY_IfYL
certify that S
1A AV
. a Notary Public of the County
State of NOV b I l"�n m hereby
appeared before me this day and under oath acknowledge that this farm was executed by him/her.
personally
Witness my hand and notarial seal,, ,thisZ day of � (AY11A (AVA 20 1
Notary Signature: ��,! AMU _C_ QaMML ,
My Commission expires: ' 1JLC t±iM T)f Y 'b I L U j,!j
0 NOIXW PUBM
�01fMK �
� � CarrmtNion SrpYaa Gao�nib�r 0�, l04A
ENWEEFAM i /IIMVV
1INM"MUM
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:[phone] Fax:[phone]
http Mandpe rm i ts. c harmeck.org
Page 2