NCC216412_FRO Submitted_20211116

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: PIN: 02965101 & 02965102, on the northeast side of
West Mallard Creek Church Road and John Adams Road.
2. Address of land —disturbing activity: 900 W Mallard Creek Church Road, Charlotte, NC 28262
3. Approximate date land -disturbing activity will commence:
Month Day
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 24.0 AC
6. List total site acreage: ±24.30 AC
7. Landowners of Record (Use blank page to list additional owners):
Name: John Wayne Adams and Catherine D Adams
Address: 14015 Woody Point RD, Charlotte, NC 28278
Telephone: [phone]
(Area Code)
Email
Signature:
Name:
com
Fax:
(Area Code)
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 34268 Page 782 Book Page
Book Page Book Page
2022
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: Flournoy Development Group, LLC
Address: P•O, Box 6566, Columbia, GA 31917-6566
Telephone: [phone], Cell 706-442-9384 Fax:
(Area Code)
Email Address: [e-mail]
(Area Code)
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: CT Corporation System
Address: 160 Mine Lake Court, Suite 200 Raleigh, NC 27615
Telephone: [phone] 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.)
Jeremy Brewer ,-U (1
Printed Name Title i R
Signature
of"� ��eJ
certify that G 4w
appeared before me this day
Witness my hand
Notary
My Commission expires;
Date
�±�1I as Notary Public of the County
State nf' c 0■ �-►f rC� , hereby
personally
under oath acknowledge that this.fori�s executed by him/her.
rl, thisDtt;�dqy of W2L 20—Cl 1
w*: 27 :*w
'. 2022 r: w
G =
�?n'0;�eco; N ���■'
Y�PV�
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpermits.charmeck.org
Page 2