NCC216969_FRO Submitted_20211216

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.
PART A Please Type or Print
1. Project where land -disturbing activity is to be undertaken: BROADSTONE SOUTH END
2. Address of land —disturbing activity: 2408 South BV, Charlotte, NC 28203
3. Approximate date land -disturbing activity will commence: NOVEMBER 1 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): MULTI -FAMILY RESIDENTIAL
5. Approximate acreage of land to be disturbed or uncovered: 2.50 AC
6. List total site acreage: 2.16 AC
7. Landowners of Record (Use blank page to Iist additional owners):
Name: AP 2408 SOUTH BLVD LLC
Address:227 WEST FOURTH ST, CHARLOTTE, NC 28202
Telephone:
(Area Code)
Email Address:
Signature:
Name:
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Fax:
Fax:
(Area Code)
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 30894 Page 800 Book
Book Page
Page
Page
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: Alliance Realty Partners, LLC
Address: 200 PROVIDENCE RD SUITE 250 CHARLOTTE NC 28207
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
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.)
(z Ac., C'. f V jC,,t P(e3
Printed 7/clz
e Title
71(t,z f
Signat e ate
I, a Notary Public of the County
of Mel* VE N BV114 cr State of hereby
certify that personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand an4 jotarial seal, Aki M day of 120 2-1
Notary Signature:
-& 5
My Commission expire :
KAISTM L. VINESETT
WIN•
Notary Public, North C.1rolina
Mecklenburg County
My Commis ion Ex ires
(31AR MTE-
ENGINEERING ffi PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http: Mandpenn its, charmeck, org
Page 2