NCC223087_FRO Submitted_20220831

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 be assigned. All relevant
items on this form must be filled out accurately and completely
Please Type or Print
PART A
1. Project name: Nathaniel Carr Senior Community
2. Address of land —disturbing activity: 2462 West Blvd. Charlotte, NC 28208
3. Approximate date land -disturbing activity will commence: September 1 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Total acreage of land to be disturbed or uncovered: 4.69 ac
G. List total site acreage: 4.54 ac
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 I, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
Name: E & M Real Estate Management LLC
Address: 3619 Davidson Highway Concord, NC 28207
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Name:
Address:
Telephone: Fax:
(Area Code)
Email Address:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 27948 Page 270
Book Page
Book Page
Book Page
Page ]

Continue - Financial Responsibility/Ownership Form
PART B
. Person(s) or firm(s) financially responsible for this land -disturbing activity (Note: Ifthe financially responsible
person(s) orftrm(s) has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: The PaceS Foundation
Address: 2730 Cumberland Blvd SE Sm rna, GA 30080
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: renee acesfoundation.or
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: Corporation Service Company
Address: 2626 Glenwood Avenue Suite 550
Ralpi h, NC 27608
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: hel csc lobal.com
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.)
The Paces Foundation, Inc. Vice President
Printe me / Title
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08/17/2022
Sig ure Date
I, a Notary Public of the County
of State of '�r: Z? �•c. hereby
certify that ELz personally
appeared before me this day and under oath acknowledge that this form was executed by4x*'her.
Witness my hand and no rial seal, this -t day of,Yli��r Zp
Notary Signature:
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http://cbarlottene.gov/develol)nienteenter Rev. 09l2021 Page 2