NCC220873_FRO Submitted_20220223

DocuSign Envelope ID: 6680316F-E1 B7-4914-B975-2168F2I34550E
13uRO
Mecklenburg County Soil Erosion and
f 1 Sedimentation Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Section 6 of the Mecklenburg
County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to
completing and filing this form with Mecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance with the above Ordinances. 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: Bed Tower Design Plans
2. Address of land -disturbing activity: 1000 Blythe Blvd, Charlotte, North Carolina
3. Approximate date land -disturbing activity will commence: March 09 2023
Month Day
4. Purpose of development (Residential, Commercial, Industrial, ete.): Healthcare
5. Approximate acreage of land to be disturbed or uncovered: 9.03 ac
6. Total site acreage: 80.95 ac
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: Charlotte Mecklenburg Hospital Authority
Address: PO Box 36022, Charlotte, NC 28236
Telephone: [phone]
Fax:
Email Address: [e-mail]
Signature:
Name: i
Telephone:
Email Address:
Fax:
8. Indicate Book and Page where the deed or instrument is Bled (use blank pages to list
additional deeds or instruments as necessary):
Book Page
Book Page
Book Page
Book Page
Year
Form Revised 12-2016
(continue on back or separate pages as necessary)

DocuSign Envelope ID: 6680316F-E1B7-4914-B975-2168F2B4550E
Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Atrium Health
Address: 1300 Blythe Blvd, Charlotte, NC 28203
Telephone:
704-280-4891
Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
Email Address:
Fax:
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.)
Printed Name
Signature /
1, Er,) i
County of N12 c
certify that
S1-) �e'1S
Title
1 I ) g I zo_)_z
Date
a Notary Public of the
State of _NDl--i+-` CCy C O 1 l 0 g-, , hereby
Sin
personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this _ day of jcqnua� , 20 Z Z .
Notary Signature:
My Commission expires:
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte, NC 28208-5237
Phone [phone]
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