NCC216673_FRO Submitted_20211201

City of Charlotte & Mecklenburg co
Soil Erosion and Sedimentationunty
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Chapter 17, Article 2 of the Char
Section 6 of the Mecklenburg County Sedimentation and Erosion Control Ordinance prior to completing form with the City of Charlotte Engineering and Property Management De tinge City Code or
or Mecklenburg County Land Development Services. The financial responsible p lSe and filing this
Department, Land Development Services Division
accept any Notices of Violation or related documents for any non-compliance of the City of Charlotte Soil th
Sedimentation Ordinance. If the financially responsible party is out of State a e Of party will be on record as the party d
North Carolina agent must be'assigned. rosion and
PART A Please Type or Print '
1. Project where land -disturbing activity is to be undertaken: Popeyes - Sunset
2. Address of land -disturbing activity: 4400 Sunset Road Charlotte NC
3. Approximate date land -disturbing activity will commence: October
1 2021
onth
4. Purpose of Development (Residential, Commercial, Industrial, etc.: Day
Year
Pp acreage 1
5. Approximate disturbed or uncovered: ) Commercial
ga of land to be disturb.1 ac
6. List total site acreage; 1.1 ac
7. Landowners of Record (Use blank page to list additional owners).
Name: Ralph Harrell Miller
4400 Sunset Road Charlotte NC 1822 g
Telephone:
(Area Code)
Email Arlr�,-p���
Signatt
Name:
Add—
C -2- q :21t
Fax:
Telephone: 74 f —3 3-- Z,fee, Fax:
(Area Code)
Email Address:
Signature:
(Area Code)
(Area Code)
A_ J^&ente Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 11109 Page 801-803 Book Page
g
Book Page Book Page
P"g l

Continue - Financial Responsibility/Ownership Form
PART B
Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Leblon Franchising Holdings, LLC (Joseph Marin)
Address: 227 West 4th Street Suite 219
Charlotte, NC 28202
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: ioseph.marin(a)-leblon-us.com
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
(Area Code)
Email Address:
Fax:
(Area Code)
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.)
lw-n-r
A-\evvk,n Vti. l S�e_
Date
a Notary Public of the County
Of ; t State of 0or4, CG.v- j1\.,,ek hereby
certify that n g--e� 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 I ate` day of yk, 4 20 ; 1
Notary Signature:
My Commission expires: 1Mq*/ I?-, 102,1
MELVIN M DUBOSE
Notary Public, North Carolina
Mecklenburg County
My Commission Expires
C AP"TTE.
May 18, 2021
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: 704,1336-6586
http://Iandpertnits.charmeck.org
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