NCC230707_FRO Submitted_20230320

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 Scrvices. The financial responsibility 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.
Please Type or Print
PART A
1_ Project where land -disturbing activity is to be undertaken: TRU by Hilton
2. Address of land -disturbing activity: 341.5_ Mulberry Church Road
3. Approximate date land -disturbing activity will commence: May 2016
4. Purpose of Development (Residential, Commercial, Industrial, etc_): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 2.3 Acres
6. List total site acreage: 3.6 Acres
7. Landowners of Record (Use blank page to list additional owners):
Name: Mulberry Systems LLC
Address: P.O_ Box 1919 Huntersville, NC 28070
Telephone: [phone] Fax: [phone]
(Area Code) (Area Code)
Email Address: [e-mail]
Signature: V ! �' _
Name: V. Jj PAT E7 L- M Gw►i3-<32 0 E b'(-
Address: P ^ 0. 31SK 1'q1 ok
1-iV '\'�iGVLS\hXX,�, rJ C_ 2-63
Telephone: 764-1 4-g Fax: -70L�,S_q $ z �'
(Area Code) (Area Code)
Email Address: ����r Qca-n�nS• °'"l
Signature-
8- Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 6017 Page 167
Book Page
Book Page
Book Page
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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: Mulberry Systems LLC_
Address: R0 Box 1919 Huntersville.NC 28070
Telephone: [phone] Fax: [phone]
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Fsrrn- �' t.1va"=S'r,ofZS � � L� `'�►J�S Iti2�i�C�s" �
Address:
d_ # ssPa f-�F4A
Telephone: 770 77? 3 2.5 Fax:
{Area Code) (Area Code)
Email Address: GGR�.i�►6�r�C fnto�'2, COS .
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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.)
Printed Na
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Signature
1 pv LDv1 -2
o fki �' ,� / State of
certify that / v
Title
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Date
a Notary Public of the County
/ t hereby
personally
appeared before me thiLay d wader oath acknnowledge that thisform was executed by him1her.
Witness my hand and eal, this O day of
� �`N� Cie �. p5' .._ ...._.. G� •.
Notary Signature: _* ''`•
My Commission expires:
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ENGINEERING & PROPEM
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: 704l336-6692 Fax:[phone]
http://Iandperniits.channeck.org
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