NCC243110_FRO Submitted_20241009

City of Charlotte Soil Erosion 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 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
1. Project name: Alexan Mallard Creek
2. Address of land—disturbing activity: 815, 911, 913, 923, 933, 937, 939, 943, 947, 951, and 1001
W. MALLARD CREEK CHURCH RD CHARLOTTE, NC 28262
3. Approximate date land-disturbing activity will commence: MARCH 30 2024
Month Day Year
4. Purpose of Development(Residential, Commercial, Industrial, etc.): RESIDENTIAL
5. Total acreage of land to be disturbed or uncovered: 12.80 AC
6. List total site acreage: 13.30 AC
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:
Name:
Address: SEE ATTACHED
Telephone: - Fax:
(Area Code) (Area Code)
Email Address:
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 30256 page 568 Book 34268 Page 794
Book 32292 Page 486 Book 1606 page 143
Page 1

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):
Person or Firm: MAPLE MULTI-FAMILY LAND SE, L.P.
Address: 4509 CREEDMOOR RD. SUITE 308
RALEIGH NC 27612
Telephone: [phone] Fax: _
(Area Code) (Area Code)
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: CT Corporation System
Address: 160 Mine Lake Ct, Ste 200
Raleigh, NC 27615
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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.) Vc K01 + 3 © Sc ces,o e/i4-
Printed Name Title
1p/s//0. 3
Signatua Date
I, JA b'ti c_ A- - S Ads H l a- , a Notary Public of the County
of (tea-kC— J State of NC— , hereby
certify that - obey--f- 11 L t3 r o o l�/"e 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 SIC. day of c) 4-- , 20)
Notary Signature:
My Commission expires: ' d we
JAMIL A SAGHIR •
NOTARY PUBLIC
WAKE COUNTY, NC (a))
My Commission Expires 69.2027.
charlottenc.gov
Storm Water Services—Land Development
600 East Fourth Street,Charlotte,North Carolina 28202-2844
Telephone: [phone]
http://charl often c.gov/deve lopmentcenter
Rev.09/2021 Page 2

815 W. Mallard Creek Church Rd
Property Owner(s): Lily Ann Elizabeth Beckham
Jennifer Metrosky(guardian)
Harriet Metrosky(guardian)
Contact: AJ Rehban—Broker
AJABhhsElite.com
704-502-7778
911, 913, and 923 W. Mallard Creek Church Rd
Property Owner(s): John Wayne Adams
Catherine Adams
Angela Adams-Crozier(Trustee of Charles Adams Estate)
Ann Adams-Hargett
Ronald Hope Adams, Jr. (Executor of the Estate of Ronald Hope Adams)
Contact: Dwaine Holden—Broker
[e-mail]
704-408-7900
933 and 937 W.Mallard Creek Church Rd
Property Owner(s): Donald F. King, Jr.,Trustee of the Miriam L. King Revocable Trust
Dennis W. King
Contact: Norman Walter- Broker
[e-mail]
704-608-0212

939, 943, 947, 951, and 1001 W.Mallard Creek Church Rd
Property Owner(s): Roxana H. Huffman, Successor Trustee Gladys Smith Hillman Trust
Sydney D. Hillman
Stephanie Hillman
Contact: Scott Knox -Broker
[e-mail]
704-607-0364