NCC222277_FRO Submitted_20220622

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Financial Responsibility/Ownership ]Corm
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: ModWash - North Tryon
2. Address of land —disturbing activity: N Tryon Street
3. Approximate date land -disturbing activity will commence:
Month Day
4. Put -pose of Development (Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 1 •$5 ac
6. List total site acreage: 1.69 ac
7. Landowners of Record (Use blank page to list additional owners):
Name: Charlotte Pavilion Road Retail Investment LLC
Address: 550 Long Point Road, Mount Pleasant, SC 29464
Telephone: g43 (,641-16$$ Fax: *0) 454-7 85 01
(Area C de) (Area Code)
Email Address:— c3�< p{ wrSh2a j�C?!n
Signature:
Name:
Address:
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a
Year
Telephone: ($43) 4'Tq - 70700 Fax: 43) &Sq - 7 $p�9 —
(Area Code) (Area Code)
Email Address: a e- WrSCafA
Signature:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book32781 Page 409 Book Page
Book Page
Book Page
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Continue - Financial Respons><bifity/Owim-ship Fop -in
PART B
i. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Hutton Charlotte Tryon NC ST, LLC
Address: 736 Cherry Street, Chattanooga, TN 37402
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Pei -son or Firm: Stewart Title Guaranty Company
Address: 223 S. West Street, Suite 900
Raleigh, NC 27603
Telephone: [phone] Fax: [phone]
(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.)
Printed Name _
4
Signature
Wi
2- . 2t "7-2
Date
a Notary Public of the County
State of VUIVI/"'� / hereby
certify that � J U
appeared before rase this day and under oath a
cknowledge that this form was execuuted by him/her.
Witness my hand and notarial seal, his ! Pj da), of t �I
Notary Signature:
* Connnission expires:
OF
TENNESS)EE)
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MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax:[phone]
http:Hlandperniits.charnieck.oE•g
personally
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