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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