NCC230705_FRO Submitted_20230315

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/ownership Form
Section 6 of the Mecklenperson shall initiate any land -disturbing activity covered by Chapter 17, Article 2 of the Charlotte City Code or
Seburg County Sedimentation and Erosion Control Ordinance prior to completing and filing this
form with the City of Charlotte Engineering and Property X"anagetnent Department, Land Development Services Division
or Mecklenburg Countyy Land Development Services. The financial responsibility party will be on record as the patty to
accept any Notices of Violation or related docmnents 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.
PART A
Please Type or Print
1. Project where land -disturbing activity is to be undertaken: OeS Riverbend
2. Address of land -disturbing activity:.3821 Coming Place
Chairlotte, North Carolina 28216
3. Approximate date Iand-disturbing activity will commence:1 2 20723
4. Purpose of DevelopmentMonth Day Year
(Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed m uncovered: 1.30
6. List total site acreage:1.23
7. Landowners of Record (Use blank page to list additional owners):
Name: RIVERBEND INVESTMENT PARTNERS II, LLC
1401 Sunset Drive Suite B
Greensboro, NC 27400
Telephone: [phone] Fax:
(Area Code) (Area Code}
Email Address' Proieetsesimosoncre-mm
Signature: Lauten Crow o n „ OrM
PRM: 2022 M1269:29:28
Name:
Telephone: Fax: _
(Area Coda} Fax:
�}
Email Address:
Signature:
8. Indicate Boak and Page where deed or insh ument is filed (Use blank page to list additional deeds nr
instruments) Book 37216
page 335
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Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firms) financially responsible for this land -disturbing activity -
Person or Firm: Bloomin` Brands, Inc.
Address: 2202 N West Shore Blvd
Tampa, FL 33607
Telephone: 813-282_ 1225 Fax:
(Area Cade) (Area Code}
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Chicago Title (Lien agent Entry #1769810)
Address:
19 W. Hargett St., Unit: 507 Raleigh, NC 27601
Telephone: [phone] Fax: [phone]
(Area Code) (Area Code) --
Email Address: supportgliensnc.com
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 farm 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 ins( nents for the
financially responsible company or entity, if not an individual.)
Jamie Butler
Printed Name
Signature
Sr. Director of Site Development & Design
Date
a Notary Public of the County
°f � .State of ,hereby
certify that �` �� �
personally
appeared before me this day and under oath Iacknowledge that this form was executed by him/her.
Witness my hand and notr�raal seal, this d day of tr—m 2� Z
Notary Signature: G, � -A�J
My Commission
PJESSICA L. BEERS
MY cOMl�gs"ON #'W65021
COP ti EXPIRES: J'M 04, 2026 �3
ENWNEEFUNG&FROpEW
Land Development Division
600 Fast Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpcmjit3.chaimuck.org
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