NCC230169_FRO Submitted_20230124

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 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.
Please Type or Print
PART A
1. Project where land -disturbing activity is to be undertaken: 300 EAST 36TH ST - MULTI -FAMILY DEVELOPMENT
2. Address of land —disturbing activity: 300 E 36TH ST (08303104), 3214 CULLMAN AVE (08303105), 3210 CULLMAN AVE
(08303106) CHARLOTTE, NC 28206
3. Approximate date land -disturbing activity will commence: 12 01
Month Day
4. Purpose of Development (Residential, Commercial, Industrial, etc.): MIXED USE
5. Approximate acreage of land to be disturbed or uncovered: 2.7 ACRES
6. List total site acreage: 3.51 ACRES
7. Landowners of Record (Use blank page to list additional owners):
Name: 300 EAST 36 DEVELOPMENT HOLDINGS LLC
Address: 51 E. 12th St
New York, NY 10003
Telephone: [phone] Fax:
(Area Code)
Email Address: JessWaveryhallinvestments.com
Signature:
Name:
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Fax:
(Area Code)
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 36897
Page 112
Book Page
Book Page
Book Page
2022
Year
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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: 300 EAST 36 DEVELOPMENT HOLDINGS LLC
Address: 51 E. 12th St
New York, NY 10003
Telephone: [phone]
Fax:
(Area Code) (Area Code)
Email Address:[e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Tarlton Long, Avery Hall
Address:
1015 East Blvd, Charlotte NC 28203
Telephone: [phone]
(Area Code)
Email Address: [e-mail]
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.)
Tarlton Long
Printed Name
Authorized Representative
Title
Z/ i l Z�
Signature // Date
C__ �K a Notary Public of the County
Of State of hereby
certify that
appeared before me this day and under oath acknowledge that this form was executed by him/her.
s�
Witness my hand and notar�j s)�pd, thise�
�, day of o „a,� 20 22-
�i
Notary Signature:
My Commission expires: tf4,-?, S�- 2,92f
•r�O * Rom.
'A CHABLOTTE.
.. \•\� , ENGINEERING & PROPERTY
CO MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpermits.charmeek.org
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