NCC220914_FRO Submitted_20220228

City of Charlotte &
Mecklenburg County
Soil Erosion '..i Sedimentation
_
Financial o° `l ei For-
No person shall initiate any land -disturbing activity covered by Chapter 17, Article 2 of the Charlotte City Cade or
Sion 6 of the Mecklenburg Count), Sedimentation and ErOsion Control Ordinance prior to completing and ding this
fora With the City of Charlotte Engineering and Property Management tent Department, Land Development Servim Division
or Mecklenburg County Land Development Ser gees. The financial responsibility party will be on record as the ply to
accept any Notices of Violation. as related documents for any non-compliance of the City of Charlotte Soil Erosion. and
Sedimentation Ordinan . if the fimincially responsible party is of of State, a North Carolina agent must be assigned.
PARTA Hesse Type or Print
I . eject where land-distutbizng activity . is to be under a en.
2. zkddress of land —disturbing activity:.._10230 fur Mvis Rd.
Charge (t€$e ur ), Nc 2az69
3. Approximate date land -disturbing activity xvili conimenct-
November 1 ztt19 _
Monti) Day Y r _
4. Purpose of eveio ent (Residential, �crercial, Industrial,
5. APPrOxilnate acreage of land t€a be; disturbed cat- uaco vered: ±i .7 At<.
6. List natal site acreage. ±23X A •
7. L I.down. rs of Rerord. (Else blaa c page to list additional ra-Anvers).
ttamy Carolina CorporaWn
Address. 2127 . yntey Town Blvd., Suite 2€ 1
Telephone: ('7GQ 507-7 7 --_.,,�.�___.__......,_,
{B_
rea ode l f Area Code)
ETnail Address:
Signature:
aMe: RME K. D201S cee Of The Aldred A, DavisRevocable Trust NX ParcW tD- 02718126)
r ddres : 1 121 Pit. Rally-Huntersville Rd.
Telephone: _ 'arc:
(Area Code)
(Area Code)
S, Indicate Book and Page where deed or instrument is filed (Use blank^ age to
instruments) look 1U2 2 Page 693 �.
Boon 30900 .__.. Page 557
Book___ Page.._
Book-__ Page
Pao I

PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Mattarny Carolina Corporation
Address: 2127 Ayrsley Town Blvd Suite 201
�harlQtke, NC 28273
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: BAjohnson mattam cor .corn
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: A
Telephone. -
(Area Code)
Email Address:
ax:
(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.)
Brian Johnson f//j,' VP of Land Development
l'tr� fi
Printed Name �~ Notary
�� % itle
Meckha bf
My c -"'Y —
14
0105 29,2 22k�
a Notary Public of the Count,
a 1 r� 7 C. t �'��i�r.� ��'�ti��l A ( �I /'V\V .' hereb3 y f _ h>icrst's
Certify that t 1 ti( t l personally
afipeared be
fare me this day and under• oath acknowledge that this form wac v executed by himllzer,
Jfitness my hand and notarial eal, this r da of 20
Notaiy Signature: a -��
* Commission exp rev
_
EMONEEMMG & PRO(E7t'iY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
'telephone: [phone] Fax: [phone]
http:l/1 andpermits.ch armeek.org
Iq
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