NCC215825_FRO Submitted_20211020

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 fling 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: 86 lot single family subdivision
2. Address of land -disturbing activity: Parcel ID 10811229, 10811227 ( no address on Polaris 3
3. Approximate date land -disturbing activity will commence: May
Month
4. Purpose of Development (Residential, Commercial, Industrial, etc.)
5. Approximate acreage of land to be disturbed or uncovered: 28.53
6. List total site acreage:
7. Landowners of Record (Use blank page to list additional owners):
Name: Nancy Coe Hall
Address: 209 Henderson St, Mount Holly, NC 28120
Day
Residential
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name:
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Fax:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 31866 page 908 Book Page
Book Page
Book Page
2020
Year
Paac l

Continue -- Financial Responsibility/Ownership Form
PART B
Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: NITS CLT, LLC
Address: 2857 Westport Rd, Charlotte, NC 28208
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
(Area Code)
Email Address:
ax:
(Area Code)
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.)
I, 1-01 11
of A
certify that
Date
a Notary Public of the County
State of N Q VbA C0 Vtl y-' CA hereby
appeared before me this day and under oath acknowledge that thisform was executed qby him/her.
Witness my hand an notarial seat, this lin day of � V t V_ U V � y `i 20
V/1;.-/ , - _ —
Notary Signature:
My Commission expires:
KAITLYN SANDS
Notary Public
North Carolina
Mecklenburg County
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 )cast Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http-.//Iandpermits,charmeck.org
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