NCC216746_FRO Submitted_20211207

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: 1734 Mineral Sp
rings Road Charlotte NC
28262
2. Address of land —disturbing activity: 1734 Mineral Springs Road, Charlotte NC 28262
3. Approximate date land -disturbing activity will commence: January 1 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): For Sale Single Family Attached
Townhomes
5. Approximate acreage of land to be disturbed or uncovered: 7.73 ac
6. List total site acreage: 11.04 ac
7. Landowners of Record (Use blank page to list additional owners):
Name: Kindred Hall Gardens LLC_CM: 04703205,.04703206. 04703207. 04703221
Address: 118 E. Kiggston Ave. S.TE 16 _T
Charlotte. NC 29203
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: adam0t.bvfioreraa.com
Signature:
Indicate Bokanage w iere deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 359,7 Page 251
Book 35957 Page 251
Book 35938 Page 971
Book 35938 Page 971
Page 1

ar-In' ue • t'1sna. Cia
PA I?-' 13
. Person(s) or lirn-,(s; l;nanc;a:;y rospo-ISih;e "o- ,,",is tared -dis:ur?ling actiX:"y:
Person or Firm
Alan Kc1'Iey
Address: 11405 N-. Community y House_RD.. Site 1.50
Charloue. NU '28277
Telephone: �(.704j_t)71`8854 Fax.
(Area Code)
Email Address:�rI1Kerley=[tr tad iormorrisan.co
(Area Codrl
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm, -
Address:
Telephone:
(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 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.)
Printed Name -, Title
-. 05/28/2021
Signature (' pate
I, f I d 1 M C (f e 11M ra Notary Public of the County
. State of t.1 v CWDli ki4 herebi•
certify that at kzr .[- ul .. _ 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 day of _ rt,e�f 20 21
Notary Signature-,
My Commiss ion expires: __t'._
OCCLEZ
WAO
1 Y
%; & PiO�9E1[ry
s pU�L Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:[phone] Fax:[phone]G
http:/Aandpermits.charmeck.org Page 2