NCC222987_FRO Submitted_20220823

City of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
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 and sedimentation control plan have been completed
and approved by the City of Charlotte. The financially responsible parry 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 form must be filled out accurately and completely
Please Type or Print
PART A
1. Project name: The Pearl: Charlotte Innovation District Phase 1A
Demolition and Early Grading, Design Package 1-1
2. Address of land —disturbing activity: 801 S McDowell St, Charlotte, NC 28203
3. Approximate date land -disturbing activity will commence: 07
Month
4. Purpose of Development (Residential, Commercial, Industrial, etc.)
5. Total acreage of land to be disturbed or uncovered: 17.5 acres
6. List total site acreage: 17.5 acres
05 2022
Day Year
Commercial
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 landowner of record or their authorized agent is required:
Name: Charlotte Mecklenburg Hospital Authority
Address: PO Box 36022, Charlotte, NC 28236
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Additional Properties:
Parcel ID
Owner
Legal Reference
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8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book See Above page See Above
Book Page
Book Page
Book Page
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity (Note: ff the financially responsible
person(s) or firm(s) has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: Atrium Health
Address: 1300 Blythe Blvd, Charlotte, NC 28203
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: Shelley.Clontz(abatriumhealth.com
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina agent:
Person or F
Address:
Telephone:
(Area Code)
Email Address:
Fax:
(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.)
kib A Aaw'yoryt 1%i'c e pyf-S i d co of 0 7'l r� �'Ssf'w;�'
Printed Name Title
Signature
4 1!
Date
a Notary Public of the County
State of-�� g ; hereby
certify that i t,� ca ,,� VYl i� ti) personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this g day of_ r , ( 20 Z ZZ
Notary Signature:
My Commission expires:
Gq
TA
EXPIRES
_ G E CR IA
APR 9, 2022 - -
� ............... . charlottenc.gov
'%/1,111CI�I,��1Storm Water Services- Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
Rev. 09/2021
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