NCC216848_FRO Submitted_20211210

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: McDonald's
2. Address of land —disturbing activity: 10720 Woodland Beaver Road Charlotte NC 28215
3. Approximate date land -disturbing activity will commence: October 1 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial- Restaurant
5. Approximate acreage of land to be disturbed or uncovered: 2.3+/-
6. List total site acreage: 2.011
7. Landowners of Record (Use blank page to list additional owners):
Name: Woodland Beaver Farms LLC C/O Erwin Capital Inc
Address: 15 Z 1 ptu%p J J-4 +. 4 t E> ,.- -
Telephone: 74 � -;r4 i ^ d � e��? Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name:
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Fax:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 28878 Page 144-151 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: McDonald's USA LLC
Address: One Glenlake Parkway, suite 50.0
Atlanta GA 30326
Telephone: [phone] Fax.
(Area Code) (Area Code)
Email Address: daryl.groet[us.mcd.com
2. North Carolina agent, for the person or firm who is financially responsible:
Pe on or Firm- Corporation Service Company
ADress: 327 Hillsborough Street, Raleigh NC 27603
Telephone: [phone]
(Area Code)
Email
ax:
(Area Code)
3. The above infonnation 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.)
Vivian Valdivia
Printed Name
Signature
Development Officer
Title
Date
11 & 7rja t? Tj$1q4?t 0 a Notary Public of the County
of ► 15bGya LAO ki State of FLCEj dO hereby
certify that (J I V 1 Ta jn V0v E d 4 Vl 61 personally
appeared before me this dory and under oath acknowledge that this form was executed by himfher.
Witness my hand and Qnotarial seal, this day of M 20 21
Notary Signature: J_,t_
My Commission expires:1 -7 t
�►"' "• ;; GINA T. WANGELO
•
,
MY COMMISSION # GG101996
F,; * • EXPIRES May 07, 2021
QH Al 10M.
ENGNMUNG d PROPERTY
MANAGEMENT
Land Development Division
600 Fast Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpennits.charmeck.org
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