NCC241910_FRO Submitted_20240621

��`^_ Mecklenburg County Soil Erosion and
Fl, Sedimentation Control Ordinance
y, a : 4�'
' Financial Responsibility/Ownership Form
No person shall initiate any land-disturbing activity covered by Section 6 of the Mecklenburg
County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to
completing and filing this form with Mecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance with the above Ordinances. 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:
Atrium Health Lake Norman Hospital
2. Address of land-disturbing activity: 18213 Statesville Road/ 1020 Tree of Life Lane
Cornelius, North Carolina
3. Approximate date land-disturbing activity will commence: April 8 2024
Month Day Year
4. Purpose of development (Residential. Commercial, Industrial, etc.): COMMERCIAL
5. Approximate acreage of land to be disturbed or uncovered: 6.15 AC
6. Total site acreage: 96.8 AC
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner#1 Name: The Charlotte-Mecklenburg Hospital Authority
Address: 9401 Arrowpoint Blvd Charlotte, NC 28273
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner#2 Name:
Address:
Telephone: Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 34138 Page 44 Book Page
Book 34138 Page 27 Book Page
(continue on back or separate pages as necessary)
Fonn Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: The Charlotte-Mecklenburg Hospital Authority
Address: 9401 ARROWPOINT BLVD CHARLOTTE, NC 28273
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax:
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.)
John S. Rawsthorne VP, Planning, Design and Construction
Printed Name Title
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gn ture Date
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1, a so{r-- ��,`4J h`}{ , a Notary Public of the
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County of /lJltc',Ltc,E,�i��j , State of 1�(�) 1 G,{.. e�e , hereby
certify that 3°>nr"- S (2—(1`.-/S}h)(fa_ personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this 13 day of M
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Notary Signature: l`1g' ✓dtyyJ %%% psiN cti
My Commission expires: 12.441024 '•�.��,o
C f,Mecklenburg County Land Use and Environmental Services Agency •
11'2145 Suttle Ave. • OLIO
Charlotte,NC 28208-5237 i 2�:•
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