NCC231192_FRO Submitted_20230426

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.
Please Type or Print •
PART A •
1. Project where land-disturbing activity is to be undertaken: 1701 EAST BOULEVARD APARTMENTS
2. Address of land—disturbing activity: 1701 EAST BOULEVARD
3. Approximate date land-disturbing activity will commence: SEPTEMBER 15,2021
Month Day Year
4. Purpose of Development(Residential,Commercial, Industrial, etc.): RESIDENTIAL APARTMENTS
5. Approximate acreage of land to be disturbed or uncovered: 2.52 ACRES
6. List total site acreage: 2.52 ACRES
7. Landowners of Record(Use blank page to list additional owners):
Name: EAST BOULEVARD DEVELOPMENT COMPANY, LLC
Address: 315 W. 9th STREET, CHARLOTTE, NC 28202
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: JIM@JIMGROSSCOMPANY_COM
Signature:
Name JAMES J. GROSS
Address: 315 W. 9th STREET, CHARLO 1-1"h,NC 28202
•
•
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) Book 3 Page 36 Book 4209 Page 673
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: EAST BOULEVARD DEVELOPMENT COMPANY,LLC
Address: 315 W. 9th STREET, CHARLOTTE., NC 28202
Telephone: [phone]) Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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.)
BRIAN S.PHILLIPS Manager
Printed Name Title
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ate
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certify that %?cii kt-- PA 111��/1 f personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and of rial seal, this day o , 20 0
Notary Signature:
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CHARLOTTE
ENGINEERINGBPROPERn ,,,,&t1RG C�\�����,,
MANAGEMENT ....11111,1N...`
Land Development Division
600 East Fourth Street,Charlotte,North Carolina 28202-2844
Telephone:[phone] Fax:[phone]
http://landpermits.charmeck.org
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