NCC222372_FRO Submitted_20220630

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: High Rise Hotels - Tyvola �.-c a �✓o.�
2. Address of land —disturbing activity: 6125 Nations Ford Road
Charlotte, NC 28217
3. Approximate date land -disturbing activity will commence:
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Multi Family _
5. Approximate acreage of land to be disturbed or uncovered: 1.793 AC
6. List total site acreage: 1.793 AC
7. Landowners of Record (Use blank page to list additional owners):
Name: The 6125 Company LLC
Address: P. O. B O X_4-�7
Davidson, NC 28036
Telephone: -704 21f( 5'3.S9 Fax: IJ ( to
(Area Cpde) _ i I (Area Code)
Email Address- M dOw
Signature:
Name:
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Fax:
-A , C-D.,
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 30905 Page 211 Book Page
Book Page Book Page
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Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: .S+e l l.c is No'cf,"41. i; 411,
Address: 12,1 3?_o Li�� 2.t•+
wlelttl. Se_ 29ra1
Telephone: Z 7 3o Fax: Y�L? 6CraI
(Area Code) (Area Code)
Email Address:_ r-pic L`!+19 V • ea M _
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
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 Names, Title
Signattuurree
I,
of.a
19 a
Date
a Notary Public of the County
State of 5actin =i{i ".__ - --_ hereby
certify that V _ 11I personally
appeared before me this day and under oath acknowledge that this form was executed by himlher.
Witness my hand and notarial seal, this _ day of ___OC- Liz , 2019
Notary Signature:
My Commission expires:
• •........,. F9 0
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Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpermits.charmeck.org
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ENGINEERING A PROPERTY
MANAGEMENT
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