NCC242111_FRO Submitted_20240716

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: Socrates Academy
2. Address of land— disturbing activity: 3909 Weddington Road(PID 23109301)
3. Approximate date land-disturbing activity will commence: AUGUST 1 2023
Month Day Year
4. Purpose of Development(Residential, Commercial, Industrial,etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered:' 4.29 AC
6. List total site acreage: 23.914 AC
7. Landowners of Record (Use blank page to list additional owners):
Name: Socrates Academy Foundation Inc.
Address:3909 Weddington Rd. Matthews NC,28105
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Signature:
Name:
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 31609 Page 840 Book Page
Book Page Book Page
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Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s)or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: Socrates Academy Foundation Inc.
Address: 3909 Weddington Rd.Matthews NC,28105
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Despina Koumantaros
Address: 3909 Weddington Rd. Matthews NC,28105
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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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
i I financially responsible company or entity, if not an individual.)
be 5p t ri.z 4tV.V0 S Treasurer of the Board of Trustees
Printed Name Title
Signature k f/ Date
i, DQ�t,ct i ° (r l'l 1 P a Notary Public of the County
of U r1 t n in , State of N C , hereby
cert fy that 0 E9 f. c,QQ.. I t 2�t3,n+O- O S personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and not 1 s 1, this 5- day of 'J (({ , 20 a 3
Notary Signature: —71, 0)c4kjit
My Commission expires: ig s I e49
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CHARLOTTE. cy
ENGINEERING&PROPERTY � 4 1
MANAGEMENT ,�0 G
Land Development Division ', le
600 East
Telephonerr704 336 6692 Fax:eet,Charlotte, 704/336-6586 Carolina 28202-2844 ���r!!10UN�������`
http://landperrnits.channeck.org
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