NCC216267_FRO Submitted_20211112

DocuSign Envelope ID: 1 B4E24F7-E728-4BA9-A879-3FB86B3E7821
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:
2. Address of land —disturbing activity
Apex Parkwood
1102 Parkwood Avenue, Charlotte, NC 28205
3. Approximate date land -disturbing activity will commence:
01
Ell
2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Mixed Use
5. Approximate acreage of land to be disturbed or uncovered: 1.03 ac
6. List total site acreage: 0.96 ac
7. Landowners of Record (Use blank page to list additional owners):
Name: Carolina Capital Reserve Fund I, LLC.
Address: 234 Johnston St
Rock Hill, Sc 29730
Telephone:
(Area Code)
Email Address:
Signature:
Name: Russell & Laura Gibbs
Address: PO Box 36062
Charlotte, NC 28236
Fax:
(Area Code)
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature: I Nssal Qfk
8. Indicate Book and
or instrument is
instruments) Book 17094 Page
Book 30609 Page
844-846
58
GiW
se blank page to list additional deeds or
Book Page
Book Page
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: Verde Homes, LLC - Ron Staley, Jr.
Address: 7427 Matthews Mint Hill, Suite 105-215
Charlotte, NC 28227 T
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: Fax:
(Area Code)
Email Address:
(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.)
Ron Staley, Jr. ! f
Printed Name Title
Signature Date
I, tin ()ta C AZ , a Notary Public of the County
Of UrA or , State of ".VtVj CUUI(rt GL hereby
certify that I:nr-\ 1 -KA
appeared before me this day and under
Witness my hand and notarseal, this
Notary Signature:
My Commission e es:
?Pis form was executed by him/her.
of PeL 202b
EMMIEUMG 3 PROPBfrY
MAM"EMENT
OOTAql.
m
A
r 08LIG
s, �F23 2�R a'tJ
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Faun: 704/336-6586
http://Iandpermits.charmeck.org
Page 2