NCC220743_FRO Submitted_20220214

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: Avery Hall 3100 N. Tryon
2. Address of land—disturbuig activity: 3100 N. Tryon St. (08303131) & 3222 N. Tryon St. (08303130)
CHARLOTTE, NC 28206
3. Approximate date land -disturbing activity will commence: 08 01 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Mixed -use
5. Approximate acreage of land to be disturbed or uncovered. 4.46
6. List total site acreage: 4.181
7. Landowners of Record (Use blank page to list additional owners):
Name: 3100 N Tryon LLC
Address: 51 E. 12th St 7th Floor
New York, NY 10003
Telephone: [phone]
(Area Code)
Email Address: [e-mail]
Signature:
Name:
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Fax:
Fax -
(Area Code)
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 35566 page 517 Book Page
Book 35000 page 555 Book Page
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or f rm(s) financially responsible for this land -disturbing activity:
Person or Firm: 3100 N Tryon LLC
Address: 51 E. 12th St 7th Floor
New York, NY 10003
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: Tarlton Long, Avery Hall
Address:
2114 Norton Road, Charlotte NO 28207
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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.)
Jesse Wark
Printed Name
Signature
4 & �Ir4: 7;
Of
certify that _
i
Authorized Representative
Title
� 02 �
ate
a Notary Public of the County
State of 'A bi-k1 _ x „_ hereby
personally
appeared before me tLtarial
and under oath acknowledge that this form was executed by him/her.
Witness my hand and seal, this day of-'r7u 120 7i
Notary Signature:
My Commissions:
Notary Pali
York O. UmIcK
tc of *W York
'40r to
'C�rd PTr.
lrc�s .
CHARLOTTE -
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 Fast Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:[phone] Fax: [phone]
http://Iandpermits.chan-neek.org
"s
Page 2
aasw, -