HomeMy WebLinkAboutNCC230327_FRO Submitted_20230203City 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: AGNES BINDER WEISIGER BREAST HEALTH CENTER
2. Address of land -disturbing activity: 315 LILLINGTON AV
CHARLOTTE NC 28233
3. Approximate date land -disturbing activity will commence: December
Month
4. Purpose of Development (Residential, Commercial, Industrial, etc.):_
5. Total acreage of land to be disturbed or uncovered: 1.89 AC
6. List total site acreage: 1.92 AC
Day
COMMERCIAL
15
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: Novant Health, Inc.
Address: 2085 Frontis Plaza Blvd
Winston-Salem, NC 27103
Telephone:704-316-4351 Fax: N/A
(Area Code) (Area Code)
Email Address: mhstiene@novanthealth.org
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 12642 page 070 Book Page
Book Page
Book Page
Page I
Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity (Note: Ifthe financially,•esponsible
persons) or,fir•m(s) has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: Novant Health, Inc
Address: 2085 Frontis Plaza Blvd
Winston-Salem, NC 27103
Telephone: 704-316-4351
N/A
(Area Code) (Area Code)
Email Address: mhstiene@novanthealth.org
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) (Area Code)
Email Address:
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.)
Matthew Stiene
Sr. VP Construction and Facility Services, Novant Health, Inc
Printed Name Title
12-&-ZZ
Signature Date
I, ��A—►l�t .) ��< L I `Shi a Notary Public of the Count),
of State of 1.)' TN 124W_ 3UJIJA hereby,
certify, that 11( !WnA<'u) �1 123„E personally,
appeared before ine this day and under oath acknowledge that this fibrin was executed by hina/her.
Ul'itness nay, hand and notarial seal, this 6- , l ^day of WCrA-AU . 20 A
Notary Signature: �R- ulX-e1Yl-S%/1
111j; Commission expires:
Kathleen M. Wilson •
NOTARY PUBLIC
Rowan County
North Carolina
My Commission Expires December 14, 2026
charlottenc.gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: 704/33 6-6692
http://charlottenc.Qov/developmentcenter
Rev. 09/2021 Page 2