HomeMy WebLinkAboutNCC216576_FRO Submitted_20211124DocuSign Envelope ID: 1EA41398-05FE-406A-8FCA-6B7FB22CAC4B
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: Bed Tower Enabling Plans
2. Address of land —disturbing activity: 1100 Blythe Blvd, Charlotte, NC
3. Approximate date land -disturbing activity will commence: July 12 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Healthcare
5. Approximate acreage of land to be disturbed or uncovered: 9.58 Acres
List total site acreage:
80.95 Acres
7. Landowners of Record (Use blank page to Iist additional owners):
Name: Charlotte Mecklenburg Hospital Authority
Address: PO Box 36022, Charlotte, NC 28236
Telephone: 704-355-1652 Fax:
(Area Code) (Area Code)
Email Addresrz..R bgg.Speakman(a7,AtriumHealth.org
Signature: )%Uf SFULLMN&
B97432COC83A4A9...
Name: Robert Speakman
Address:
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 04438 page 468 Book Page
Book Page Book Page
Page I
DocuSign Envelope ID: 1 EA41398-05FE-406A-SFCA-6B7FB22CAC4B
Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Atrium Health
Address: 1300 Blythe Blvd Charlotte NC 28203
Telephone: 704-355-1652 Fax:
(Area Code) (Area Code)
Email Address: Robert. S eakman AtriumHealth.or
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Fi
Address:
Telephone:
(Area Code)
Email Address:
Fax:
(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.)
Em1\w maYke, wQ C-00faina---or
Printed Name Title
Signature
I,
Of
certify that
-� l'�_ �L�
Dae
a Notary Public of the County
State hereby
personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this day of 20 d—
Notary Signature:
My Commission expires:
•
QMA "TTE.
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: 704/336-6692 Fax: 704/336-6586
http://Iandpennits. charmeck, org
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