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HomeMy WebLinkAboutNCC233187_FRO Submitted_20231025 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: Centene East Coast Headquarters 2. Address of land-disturbing activity: 2405 Governor Hunt Road, Charlotte, NC 28262 3. Approximate date land-disturbing activity will commence: January 4 2021 Month Day Year 4. Purpose of Development(Residential,Commercial,Industrial,etc.): office commercial 5. Approximate acreage of land to be disturbed or uncovered: 33.01 6. List total site acreage: 80.7 7. Landowners of Record(Use blank page to list additional owners): Name: Centene Management Co., LLC Address: 7700 Forsyth Blvd., St. Louis, MO 63105 Telephone: (314) 721-8427 Fax: (314)721-8533 (Area Code) (Area Code) Email Address: Signature: f Name: c,Q PG 0e.�`- 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) Book 34792 Page 819-834 Book _ Page Book Page Book Page Page 1 Continue - Financial Responsibility/Ownership Form PART B 1. Person(s) or firm(s)financially responsible for this land-disturbing activity: Person or Firm: Centene Management Co., LLC Address: 7700 Forsyth Blvd.. St. Louis, MO 63105 Telephone: (314) 721-8427 Fax: (314) 721-8533 (Area Code) (Area Code) Email Address: tim@rafcoprop.com 2. North Carolina agent,for the person or firm who is financially responsible: Person or Firm: �Ari&-24-.1 12.?2 �• G G c .2&to irrt c N/ 51-S7 w1 Address: I let) !til a We— L.641G- Gnv IL1 S V tZ r.244:14 IZAtza tGH, r4C z.7Gt c L4 r- Telephone: Coll 9f) 4.4" - g 4.0 Fax: (Area ode) (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.) (f , I - '��.-I,C� Gg,(41442.5 12.gi9 ri.ascwTit j toe. Printed Name Title ktna Date rrII 1 tr2r, n (11-171,i l� , a Notary Public of the County of SA . U)Lt t � ,, , State of VU t S S CLA.r i , hereby cert fy ! that_ Ob`ltl 5 4Lfo,QA personally appeared before me this day and under oath acknowledge that this form was executed by him/her. Witness my hand and n lanai seal, this day of cerrvAb2+� , 20 <DO Notary Signature: i (R 2L - - - My Commissio,a expires: Q3-aS -aaDac- HEATHER LYNN RIZZELLO NOTARY PUBUC-NOTARY SEAL STATE OF MISSOURI • COMMISSIONED FOR ST.LOUIS COUNTY (C1X MY COMMISSIION EXPIRES MAK 25,2022 ID.18906933 ClEARLOTTIL ENGa18WNG a PROPERTY MANAGEMENT Land Development Division 600 East Fourth Street,Charlotte,North Carolina 28202-2844 Telephone:704/336-6692 Fax:704/336-6586 http://landpermits.charrneck.org Page 2