NCC231891_FRO Submitted_20230620

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A.1. Project Name Eastland Major Infrastructure On-Site
2. Location of land-disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street Central Avenue Latitude 35.208126 Longitude-80.751003
3. Approximate date land-disturbing activity will commence:July 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
Residential &Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 77.37 acres
6. Amount of fee enclosed: $ 5,070.00 . The application fee of$65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Barry James E-mail Address [e-mail]
Telephone(704) - 561 - 5200 Cell # Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Charlotte (704) - 336 - 7600
Name Telephone Fax Number
600 E. Fourth St 600 E. Fourth St
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
10. Deed Book No.27628 Page No.$51 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
C4 Development, LLC [e-mail]
Name E-mail Address
121 W. Trade St 121 W. Trade St
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
Telephone(704) - 561 - 5200 Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
C4 Development, LLC [e-mail]
Name of Registered Agent E-mail Address
121 W. Trade St 121 W. Trade St
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
Telephone (704) - 561 - 5200 Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Barry James Partner
Type or print name Title or Authority
2571
Signatu Date
Jthanito S'}nnorai , a Notary Public of the County of CVNicland
State of North Carolina, hereby certify that Bq j r`I Soy r-''e s appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 11 day of July , 20 22
'JvTA SINo
O T Notary
Seal = ;, N ARC
+0 My commission expires
C/gL%C . j .

Continued - Financial Responsibility/Ownership Form
9. Landowner(s) of Record:
Name: City of Charlotte
Telephone: (704) - 336 - 7600
Current Mailing Address: 600 E. Trade Street Suite 300, Charlotte,NC 28202
Current Street Address: 600 E. Trade Street Suite 300, Charlotte,NC 28202
10. Deed Book No. 35438 Page No. 228
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