NCC222968_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 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 he avoigned. All relevant
items on this form mu%l he filled out accurately and completely
Please Type or Print
PART A
L Project name: Arc Ministries Mass Grading Plan
2. Address of land -disturbing activity: I Plaza Road Extension
3. Approximate date land -disturbing activity will commence:
4
August 15th
Month Day
Purpose of De.•elopment (Residential, Commercial, Industrial, etc.): Institutional
S. Total acreage of land to be disturbed or uncovered: 3.64
5. List total site acreage:
2022
Year
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 landowner of record or their authorized agent is required:
Name: Robert Merriwether
Address: 3324 Wrangler Lane
Telephone: [phone] Fax:
Area Code) (Area Code)
Email Address: arcministriesi nc@q mail corn
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 36709 page 589 Book 03245 page 415
Book 33337 page 678 Book Page
Page I

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firms) financially responsible for this land-dititurbing activity (Note: If thefinancialty responsible
person(s) or frrm(s) has an out -of -stare address, a North Carolina agent must he designated in item 2 below):
Person or Firm: Arc Ministries
Address: 3324 Wrangler Lane
Uharlotte, NC 28213
Telephone: [phone] Fax:
(Area Codc)
Email Address: [e-mail]
(Area Code)
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 Firm:
Address:
Telephone: Fax:
(Area Code)
Email Address:
(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.)
Title
Signature
?-1t-��aa
Date
!� a Notary Public of the County
of . State of N L hereby
certify that k*ev t Lt{ P�`i Iw eiA ze personally
appeared before me this day and under oath acknowledge that this form was executed by himlher.
Witness my hand and notarial seal, this Df 4A 20 -2'11'
Notary Signature:
My Commission expires: �j.17'Lp 7-
charlottenc.gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]b92
htlp:!/chartuttenc.gov/developmentcenEcr