NCC232119_FRO Submitted_20230718

City of Charlotte Soil Erosion and
Sedimentation
1.
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land-disturbing activity on one or more acres as covered by Chapter 17 of the Charlotte
City Code of Ordinances before this form and an acceptable erosion and sedimentation control plan have been completed
and approved by the City of Charlotte.The financially responsible 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. All relevant
items on this form must be filled out accurately and completely
Please Type or Print
PART A
I. Project name: C.W. Williams Community Health Center, Inc.
2. Address of land—disturbing activity: 3333 Wilkinson Blvd
6/1/22
3. Approximate date land-disturbing activity will commence:
onth
4. Purpose of Development(Residential, Commercial, Industrial,etc.): Healthcareay Year
5. Total acreage of land to be disturbed or uncovered: 1.4
6. List total site acreage:_ 1.4
7. Landowners of Record(attach accompanied page to list additional owners). If the landowner of record is not
the person(s) or firm(s)financially responsible as listed in Part B, item 1, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
C.W. Williams Community Health Center, Inc.
Name:
Address: 3333 Wilkinson Blvd, Charlotte, NC 28208
Telephone:_ 704-391-0819 Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Name:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
8. Indicate Book and Page where deed or instrument is filed(Use blank page to list additional deeds or
instruments) Book 5015 Page 607 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 (Note:If the.financially responsible
person(s)or firm(s)has an out-of-state address, a North Carolina agent must be designated in item 2 below): j
Person or Firm: C.W.Williams Community Health Center, Inc. i
Address: 3333 Wilkinson Blvd. Charlotte, NC 28208 1.
Telephone: [phone] Fax:
(Area Code) (Area Code) i�
Email Address: [e-mail]
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina agent:
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.)
Debra Weeks Chief Executive Officer
Printed Name Title
' ; '
_ 04/01/2022
Signature Date
1
I, �ca S bd C -v$`)--*-• , a Notary Public of the County
of M c-kl,ev,buy State of Ni()(( "Kt. CaY() (tn9 , hereby
certify that ��CP klcA W e A(S personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this day of pip Ir:1- , 20 7-2
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Notary Signature: V`3i i C�-l . . .,.c6tN- Al�fft /,
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My Commission expires: `/30/077273 ���' •��
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charlottenc.gov
Storm Water Services—Land Development
600 East Fourth Street,Charlotte,North Carolina 28202-2844
Telephone: [phone]
http: ichariottenc._=m decelopmentcenter
Rev.09/2021 Page 2