NCC221981_FRO Submitted_20220526

City of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
Financial Responsibility/Ownership Forin
No person shall initiate any land -disturbing activity on one or more acres as covered by Chapter 17 of the Charlotte
City Code of Ordinances before this form and an acceptable erosion andsedimentation control plan have been completed
and approved by the City of Charlotte. The financially responsible 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. All relevant
items on this forni must be filled out accurately and completely
PART A
1. Project name.
Please Type or Print
Verizon North Mecklenburg
2. Address of land ---disturbing activity: 9500 Research Dr. Charlotte NC, 28262
3. Approximate (late land -disturbing activity will cornmence: April 29 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial
S. Total acreage of land to be disturbed or uncovered:11.39 Acres
6. List total site acreage: 17.28 Acres
7, Landowners of Record (attach accompanied page to list additional owners). If the landowner of record is not
the person(s) or firm(s) financially responsible as listed in Part B, item 1, a separate letter of consent signed
by the Iandowner of record or their authorized agent is required:
�..s. Ir uc .�ltczuc
Address: 8921 Research Dr, Charlotte NC. 28262
Telephone: 7 04 - 5 6 2- 5 9 8 9 Fax:
(Area Code) (Area Code)
Email Address: -,[e-mail]
Name,-
Address -
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 26940 page 583 - Book Page
Book Page Book —page
vage I

Continue -Financial Responsibility/Ownership Form
PAI;rr 13
f . I�e1`SOt7(S} Ot' fii'I7i(S} f inanClally rCSpOnSll)le fnl' this lat7tl-distlil'blllg activity {Note: lI-tlre fr,rrl,rclzrll},c,rljwrsil,lc+
person(v) or,irm(s) hers• rnr out-aJ=state address, a North Caralims agent „rust be desigtialecl in item 2 below):
person Or I,,`i1.111: Clyde Shade
Address: 8921 Research pr, Charlotte NC 28262
Telephone: 704 - 562-5989
aX:
(Area Code) (Area Code)
i hail Address: [e-mail]
2. If (lie Financially Responsible Party is not a resident ofNorth Carolina, give name and street address of* tlie
designated North Carolina agent:
Person or Firm:
Address:
Telephone: Fax:
(Arcs► Code) (Area Code)
Email Address:
3, The above, information is trtle and correct to the best of my knowledge anti beliel'and was provided by me
While uncler oath. (Hiis form must be signed by the financially responsible person if an individual or by an
officer, director, partner, attorn ey-i it -fact, or Other person with altthOl'ity tO eXCCtite inStrlinlents for the
financially responsible company or entity, if not ati inclivi(ltial.)
Printed Mune I itic
Q _``
Signature
�fel- ���� _ State of
cerltl}+ firer!
appeared bejvr'e rue this day and under oath acknowledge that this
11,71ness ruv hand and notarial seed, this i day
4,
Nolcrr j+ 5'i�rtcr!?t � .�, a
,fly Cc,ururissir�rf e y s
tale
a Nolu,1' Public of Me C*ounfy,
was executed by him/her.
2e
hereby
Page 2
Rev, 0912021