NCC215195_FRO Submitted_20210916

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 Codc or
Section 6 of the kleckleriburg County Sedimentation and Erosion Control Ordinance prior to completing and filing this
form with the City of Charlotte Engineering and Property Managemenl 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: BUSINESS CENTER DRIVE WAREHOUSE
2. .Address of land disturbing activity: 4250 BUSINESS CENTER DR., CHARLOTTE, NC 28214
PID #05535101, 05535131 & 05535334
4.
Approximate data land -disturbing activity will commence: MAY Year
Month Day
Purpose of Development (Residential, Commercial, Industrial, etc.): INDUSTRIAL WAREHOUDE
5. Approximate acreage of land to be disturbed or uncovered: 11.0
6. List total site acreage: 13.2
7. Lando,,vners of Record (Use blank page to list additional owners):
Name: PARK'N GO CHARLOTTE 2 LLC
Address: PO BO
V � iZ t?
Telephone: -
Email Address
43804
1
000C�J CG 3lcg (I Li
951.9L71- y1;9q Fax:
(Area Code A r-n P1A 1Zk N 670. U S
'1 i /
(Area Code)
-
NIVame: K,,_ r lrtZ LD AtA 2ezu:0 2GCpc5VNT-Arlvk
Address: PU K VX (,'f 3 60,{
t✓(Zu AeAev4 FL 37,s(.3
Telephone:
Email Address:
(Area Code)
Fax:
(Area Code)
2021
Signature:
8. indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 33177 Page 686(pID: 05535101) Book 33177 Page 686 (PID: 05535334)
Book J3177 Page 686(PID: 05535131) 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: CP AIR 85, LLC — John Collett
Address: 1111 METROPOLITAN AVE., SUITE 700
CHARLOTTE, NC 28204
Telephone: [phone] Fax: [phone]
(Area Code) (Area Code)
Email Address: Primary: [e-mail] Secondary: [e-mail]
2. North Carolina agent, for the person or fine who is financially responsible:
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 Name 'Title
°9'21
Date
1, OM PYCryLQ. (^ np 1 1511 , a Notary Public of the County
of U /U. i o n . State of k%rttz rot, i c �6 . hereby
certify that S H n Colle-6 - personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notffial seal, this dory of MC KCil 20
Notary Signature:
My Commission expires:
•
WD
CHARLOTTIL
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://iandpermits.charineck.org
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