NCC222512_FRO Submitted_20220713

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 urith the City of Charlotte Engineering and Property Management Department, rand Development Services Division
or Mecklenburg County Land Development Services. The financial responsibility party will be an 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: Bailey Run
2. Address of land —disturbing activity: 3425 Rocky River Road
Charlotte (Mecklenburg), NC 28215
3. Approximate date land -disturbing activity will commence: January 10 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: ±38.0 AC.
6. List total site acreage: ±41.32 AC.
7. Landowners of Record (Use blank page to list additional owners):
Name: Edward Andrew Hodges. 'rrr �C�r� r-,�se rne�h�C Cte�r� tEY�d'es�ge,
1
Ad&eSS: 4475 Creemore Drive
Charlotte, NC 28213
Telephone: 70 — q TS—0 a Fax;
(Area Code) (Area Code)
Email Add aov
Signature:
Name, Betty H. Lloyd {
Address. 4030 Back Creek Church Road
Charlotte, NC 23213
Telephone: Fare:
(Area Code) (Area Code)
Email Address: _
S. Indicate Book and PatrVwhere. deed & instrument is
instn ments) Book 27548 page 219
Book 20446 _ Page
663
(Use blank page to list additional deeds or
Book 20446 page
Book 26992 page
666
302
Book 07606 Page
866
Book 07606 Page
NO Page i

NaMc: Eugene W III Hodges
AddTess: 7230 Hideaway Lane
Newland, NC 28657
Telephone
Email Add
Signature:

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Mattamyr Carolina Corporation
Address: 2127 Ayrsley Tom Blvd., Suite 202
Charlotte NC 28273
Telephone: (704) S07-7547 - Fax:
(Area Code) (Area Code)
Email Address: gA. ohnmon•mattarn .corn
2. North Carolina agent, for the person or firm who is financially responsible:
Person ur Firin: N/A
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.)
Brian Johnson
Print Name
signature
1�-
cert o that VY L I
appeared before me this clay and
Witness my hand and notaria ,
Notary Signature:
My Commission expires:
V.P. of Land Development
Title
Date
. a Notary Public of the County
State of �?C �� c'�'1����- hereby
oath acknowledge that this
day of,
•
CHABLOTM
MJ UM"araoramr
wuuawDU
by him/her.
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2&W
Telephone: [phone] Fax: [phone]
httpJAandpeimits.channeck.org
10-L�
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