HomeMy WebLinkAboutNCC215448_FRO Submitted_20211004City of 1 t g Coon
SoilErosionand '
Control I e
Financial Responsibility/Ownership Form
o person sW initiate any latkWisturbat tivity covered er 1 ? . Artie ? of the Cbarlotte City CAide or
Sc ion 6 of dw ? mkilenburg Coun�-° dimcntation and Erii%i In Oyntrol (*d nancc prior to cornpleting .mac# filing aria
form with the City of C; %!te # nginccring and Property Managmcnt 13cpwtmcnt, Land Mvelopment ScTviccs Division
ion
or Mcckicnburg Coun�v Land Development Sergi*ins. The fuwxial responsibility pam, will be on record as the sty to
accept and Notices of Violation or related documents for ai y non-compliance of the C€ty of Charlotte Soil Erosion
Sedimentation Ordinance- If the tinanc:iaily responsible party is out of State. a North Carolina aggent roust he assigned_
Pkase Type or Print
PART A
1. Project where land-di.qturbing ,activity is Ui he undertaken
I Acidrrss of lanckli urbiugr activity:49M Old Piro Rand Charl
>, Approxin to cl i:l Nl-disturbing €u:t vity will t7tmencC: t 2OV,
lantta
. ;p`urposc of Dcvelopment (R:csidcnti4 Commcrcial. lodustziad, c le. ); =-. �
_ Approximate acme of land to he quror LtntWenUL* 1.79 acres
6. List total site acre l c: 1,61 mom
7. Landovmm of Record (13se. blank page to list additional owners):
Na.; Heartreen �
,,ddrm, PO Box 240881 Charlotte, NC 28224
1 ele hones ` ?,,5:Fax:
(AreaCodc) t:arj C(ACi
Email
Signto
Nam;
t Area Ox�-.) (Am Code)
Email Address:
signature:
8< Indicatic �figc whcm-dv,,mJor instr anent is. tiled (Use blank Me to list additiortal deeds or
ingtruments) BOX*
Book 2M6 Page
Book Page
lcitrk .. ..Pape
Continue - Financial Responsibility/Ownership Form
PART B
I. P t s or %(s) financially responsible for this land-disturbingactivity.-
(Area Cam) 0.= cok)
Ettl Address. bendeflA
2. North Carolina agent, for the peroon or firm who is financially r iblc
Tcic onc: 6,ra.. r,44t i Fax:
(Arcs Co&) f-AM CO*)
I The above information is true and corma w the best of my kpowlaJge and bcli f andprovided by me
while under oath, (This forms must be sited l the financially rcsponsible person if an irdi " or by on
o iccrt director. partner, attorney -in -fit, or odwr person with mohority to execute its. €-unwrits for the
financially responsible cotnpany or entity, irmt an individual.)
Title
_?ft!
c•vrtdti that
RM
appeared beftc me thkv &ky and wtder n th acknawledge thAw thkfivm wav ereewd In, howYher.
tf iox!ss r w hamI and p urr` seal. a his dlm?
:t {fit C"r%.r`rn arrs. %'1— a
�I" z4 S. M"i'Uo %
Q. �V�,
OU IAgy .
land DcvcbDpmcnt Division
600 FAA F&xih Street, C hw o , North C.amfina 29202-2844
Tc c: #,` 3(""92 Fax: 7 ?3 sfr 596
;rsstly.
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