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HomeMy WebLinkAboutNCC216267_FRO Submitted_20211112DocuSign 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: 980-272-2015 Fax: (Area Code) (Area Code) Email Address: staleyr@myvh.net 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: 704/336-6692 Faun: 704/336-6586 http://Iandpermits.charmeck.org Page 2