NCC233798_FRO Submitted_20231222

City of Charlotte Soil Er
osion and
Sedimentation
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 Ordinancesi before this form and an acceptable erosion and sedimentation control plan have been completed
and approved by the Cityiof Charlotte.The financially responsible party will be on record as the party to accept any Notices
of Violation or related locwnents 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 bile filled out accurately and completely
Please Type or Print
PART A
1. Project name: Eastern Spec.Warehouse
2. Address of land-disturbing activity: 10909 Rozzelles Pony Rd,Charlotte,NC 28214
3. Approximate date land-disturbing activity will commence: Febmary 1 2023
Month Day Year
4. Purpose of Development(Residential, Commercial,Industrial,etc.): Industrial Building
5. Total acreage of land to be disturbed or uncovered: ±1.31 AC
6. List total site acreage: 2.15 AC
7. Landowners of Record(attach accompanied page to list additional owners). If the landowner of record is not
the person(s)or flings)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:
Name: Roth4 Holdings LLC
Address: 10909 Rozzelles FerryRd,Charlotte.NC 28214
Telephone: 8 -431.9016 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 33506 Page 347 Book Page
Book Page . Book Page
Foga I

Continue - Financial Responsibility/Ownership Form
4
PART B
1. Person(s)or firm(i)financially responsible for this land-disturbing activity(Note:If the financially responsible
person(s)orfirm(s)has an out-of-state address,a North Carolina agent must be designated in item 2 below):
Person or Finn: Roth4 Holdings LLC
Address: 10909 Rbzzelles Feny Rd.Charlotte,NC 28214
Telephone: [phone] Fax:
(Area Code) (Area Code)
Entail 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 ine
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.)
Derek$Rothaupt Owner
Panted Name a - Title 4/;
Signature
Date
p� , a Notary Public of the County
k of Ar�, Stateo '
f C- ,hereby
certify that 444-V personally
appeared before me this day and under oath ad owledge that this form was executed by him/her.
Witness my hand and no l se this day of Tan. 2
Notary Signature: •
My Commission expires: 0
A EL RKC?4A6S
Notary Pwbllc
Cabarrus County, North;Carolina
My Commission Exp. Jan 10, 2024
charlottencegov
Storm Water Services—Land Development
600 East Fourth Street,Charlotte,North Carolina 28202-2844
Telephone:[phone]
htto://chariottene.gov/developr ioateenter
Rev.S19/2021.
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