NCC223674_FRO Submitted_20221116

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: Park Stroll Single -Family
2. Address of land —disturbing activity: 2733 Arnold Drive, Charlotte NC. 28205 v
3. Approximate date land -disturbing activity will commence: September 15 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential - Single Family
5. Approximate acreage of land to be disturbed or uncovered: 1.49 Ac
6. List total site acreage:
1.57 Ac
7. Landowners of Record (Use blank page to list additional owners):
Name: Selwyn Capital LLC, Buckhead Capital LLC
Address: 2824 Briarcliff Place, Charlotte NC 28207
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 35974 Page 532 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: The Building Agency LLC. (Thom Miller)
Address: 105 Elmore St. Belmont, NC 28012
Telephone: [phone]
(Area Code)
Email Address: [e-mail]
Fax:
(Area Code)
2. North Carolina agent, for the person or firm who is financially responsible:
Person or
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.) (�
Prinw&Wam-1 z Title
I,
a
Date
a Notary Public of the County
af_�[�1� State of hereby
certify that %pmtU MiCr personally
appeared before me this day and under oath
Witness my hand and notarial
Notary Signature:
My Commission expires:
was executed by him/her.
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ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpermits.charmeck.org
20 ZI
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