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HomeMy WebLinkAboutNCC233169_FRO Submitted_20231113 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 East Lane TownHomes for Habitat For Humanity of the Charlotte Region 1. Project name: 2. Address of land—disturbing activity:East Lane Drive, Charlotte NC. Parcel PINs: 16512123, 16512119 3. Approximate date land-disturbing activity will commence: 2 1 2023 Month Day Year 4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential 5. Total acreage of land to be disturbed or uncovered: 2.20 acres 6. List total site acreage: 2.50 acres 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: Habitat for Humanity of the Charlotte Region, Inc. Address: 3815 Latrobe Dr, Charlotte, NC 28211 Telephone: 980-423-8239 Fax: (Area Code) (Area Code) Email Address: bglusenkarnp@habitatchregion.org 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 35970 Page 576 Book Page Book 35970 Page 576 Book Page Page I Continue - Financial Responsibility/Ownership Form PART B 1. Person(s) or firm(s) financially responsible for this land-disturbing activity(Note:tithe 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: Habitat For Humanity of the Charlotte Region Address: 3815 Latrobe Dr, Charlotte,NC 28211 Telephone: 980-423-8239 Fax: (Area Code) (Area Code) Email Address: bglusenkamp@habitatcltregion.org 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 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 to Title (Jr 7,421417Okb L `3v ZDZ-2- Signature 'A Dat I, \SQ(G Vvu�� � , a Notary Public of the County of metaef \our , State of NUi Ca nhi 1Ci hereby cert 'that mob Ivan10tli.� SV? conPylktui 0,vreAtiolic personally appeared before me this day and under oath acknowledge that this form was executed by hint/her. Witness my hand and tar/al seal, this SO day of No'2m bP r , 20 ZZ Notaty Signature: ( V My Commission expires: -2-CP ' 2025 Notary PublicMI) Mecklenburg County My Comm. Exp. 2 08-26-2023 �Q-\�� charlottenc.gov "'//�T 1 C AFt,°\',0 Storm Water Services—Land Development 600 East Fourth Street,Charlotte,North Carolina 28202-2844 Telephone: 704/3 3 6-6692 http://charlottenc.gov/developmentcenter Rev.09/2021 Page 2