NCC215738_FRO Submitted_20211015

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:
Starbucks
2. Address of land —disturbing activity: 3809 East Independence Boulevard - Charlotte, NC 28233
3. Approximate date land -disturbing activity will commence. May 1, 2021
Month
4. Purpose of Development (Residential, Commercial, Industrial, etc.):
5. Approximate acreage of land to be disturbed or uncovered: 2.10
6. List total site acreage: 4.24
7. Landowners of Record (Use blank page to list additional owners):
Name: Executive Building Company, LLC
P.O. Box 33726 - Charlotte, NC 28233
Day
Commercial
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Signature: C2�'�
Name: 4 r%�._
Address:
Telephone: Fax:
(Area Code)
Email Address:
Signature:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 09816 Page 0703-0709
Book Page
1
Book
Page
Page
Year
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: C4 Independence, LLC
Address: 121 West Trade Street, Suite 2550 - Charlotte, NC 28202
Telephone: [phone]
ax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Oak Engineering PLLC (Luke Bugenske)
Address: 4929 Monroe Road, Charlotte, NC 28205
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.)
41' box P ►,k
Printed Name Title
?I 2
Signature l Date
n ra Notary Public of the County
of 2�� %,.nr tt State of & Cue Y o � i., K. hereby
certify that = 0�0 J_a,n C- personally
appeared before me this day and tinder oath acknowledge that thisform was executed by him/her.
Witness my hand and notgrial seal, this � t �r day of MCArl-- L 20 Z I
Notary Signature:
My Commission expiry: o r, j Z. 0 t
JAMES R. DILLEN
NOTARY PUBLIC
Mecklenburg County, North Carolina
i
(11AU01 115.
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax-. 704/336-6586
http://Iandpermits.channeek.org
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