NCC216698_FRO Submitted_20211203

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:
The Meadows at Plato Price
2. Address of land —disturbing activity: Morris Field Dr. Charlotte, NC 28208 PARCEL ID: 11711122
3. Approximate date land -disturbing activity will commence: August 20 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
S. Approximate acreage of land to be disturbed or uncovered: 8.76 acres
6. List total site acreage: 9.10 acres
7. Landowners of Record (Use blank page to list additional owners):
Name: HABITAT CHARLOTTE PROPERTIES, LLC.
Address: 3815 LATROBE DRIVE, CHARLOTTE, NC 28211
Telephone. [phone] Fax:
(Area Code) (Area Code)
Email Addresses:_(,1BARTONQHABITATCLTREGION ORC
Signature: �t�udteja%a�- �• Si"a�
Name: Robert Hill
Address: yAoS XOR2tS F/lfGJ J)QAv4f
C1442coTM, NL ; .10S
Telephone: Fax:
(Area Code)
Email Addr N 1A oe f'
Signature• G�
Indicate Book
Page where deed or instrument is filed (U_ _ _ ______ r_o_ __ ____ ___ __________ _____ __
(Area Code)
instruments) Book 34101 Page 968
Book Page
Book Page
Book Page
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Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: HABITAT FOR HUMANITY OF THE CHARLOTTE REGION INC.
Address: 3815 LATROBE DRIVE CHARLOTTE NC 28211
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: CBARTON(o)_HABITATCLTREGION.ORG
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.)
CHRISTOPHER B. BARTON
DIR. OR LAND ACQUISITION & DEVELOPMENT
Title
6 2f 2 /
__ D to
17' at:q�2))Uiizon , a Notary Public of the County
of M e c e6b State of N . �' , hereby
certify that
personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and tpoTai ' se ,his Z I day of :� 20
Notary Signature:
My Commission expires:
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Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:[phone] Fax:[phone]
http://landpermits.charmeck.org
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