NCC230023_FRO Submitted_20230105

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 parry 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: All Nations United Church - Parking Lot Expansion
2. Address of land —disturbing activity: 11440 Shopton Road West
3. Approximate date land -disturbing activity will commence: October 3 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Religious
Total acreage of land to be disturbed or uncovered: 5.48 Ac
6. List total site acreage: 15.18 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 1, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
Name: All Nations United Methodist Church
Address: 11440 Shopton Road West, Charlotte, NC 28278
Telephone:
Fax:
(Area Code) (Area Code)
Email Address:
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 32474
Page 600
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: If the financially responsible
person(s) or firms) has an out-of-state address, a North Carolina agent must be designated in item .2 below):
Person or Firm: Master Works LLC
Address: 1 442 Fields -tone Trace, Charlotte NC 28278
Telephone: [phone] Fax:
(Area Code) (Arta Codc)
Email Address: Jose hnboak e@ ahoo.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 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.)
Joseph Boakye
Printed Name
Signature
certify that I IcElf k% I
appeared before me this day and under
Witness my hand and not
Notary Signature:
My Commission expires:
BRIGITTE TSOMOS
Notary Public, North Carolina
Iredell County
My Co iss on Ex Tres
Rcv.09/2021
General Manager
Title
10
Date
a A'otary Public of the County
State of a LlnL� , hereby
acknowledge that this farm was executed by him/her.
charlottenc.gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
http-.//cbarlottene.gov/developmentcenter
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