NCC231004_FRO Submitted_20230414

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 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.
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PART A
1. Project where land-disturbing activity is to be undertaken: 136 Sardis Lane
2. Address of land—disturbing activity:_136 Sardis Lane
3. Approximate date land-disturbing activity will commence: 11 01 2021
Month Day Year
4. Purpose of Development(Residential, Commercial, Industrial, etc.):Residential
5. Approximate acreage of land to be disturbed or uncovered: 1.93 ac
6. List total site acreage: 2.17 ac
7. Landowners of Record (Use blank page to list additional owners):
Name: Ricab, LLC
Address: 136 Sardis Lane
Charlotte, NC 28270
Telephone: _ Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
8. Indicate Book and Page where deed or instrument is filed(Use blank page to list additional deeds or
instruments) Book36174 Page 968 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:
Person or Firm: Juan Gomez
Address: 5009 Monroe Rd, Suite 201
Charlotte, NC 28205
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: juanArivusnc.com
2. North Carolina agent, for the person or firm who is financially responsible:
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.)
JUAN GOMEZ MANAGER
Printed Name JVC4 ✓ Title
ju to 5t7iYL2'L �// 8/10/2021
Signature CV/ Date
�, �ru✓Y) 1 (Jh� Li 1 , a Notary Publicof the Counn'
of Me G b 60e0.1. , State of NpY-+'� ('..Your . hereby
certifi•that 3 . t,e) personally
appeared before me this day and under oath acknowledge that this fbrmnwas executed by him/her.
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Witness my hand and notari seal, This I0 4- day of (,L y U,S4 . 02
Notary Signatur . / `/
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MANAGEMENT {.. [� (�' /.V -J 2
Land Uri elopment Division nt (l LtC
600 East Fourth Street,Charlotte, North Carolina 28202-2844 �S FN JF
Telephone: [phone] Fax: [phone] 4 eiIt iMG C���``,
http://landpermits.charmeck.org