NCC220090_FRO Submitted_20220106

DocuSign Envelope ID: 91B8B5CB-1896-4C11-BC73-DBCBF9ICECD6
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: Mayfield Affordable Housing
2. Address of land -disturbing activity: 726 W Sugar Creek Road, Charlotte, NC 28213
3. Approximate date land -disturbing activity will commence: August 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: 3.87 Acres
6. List total site acreage: 3.56 Acres
7. Landowners of Record (Use blank page to list additional owners):
Name: Mayfield Memorial Baptist Church TRS (Parcel 08904202)
700 W Sugar Creek Road, Charlotte NC 28213
Telephone:
Code
Email
Signature:
Fax:
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smith(a�carolina.rr.C()MDocuSigned q:
Name: Mayfield Memorial Baptist Church TRS (Parcel 08904208)
. 700 West Sugar Creek Rd. Charlotte, NC 28213
Telephone:
Email Ad
Signature:
Area Code)
[e-mail]
Q
Fax:
(Area Code)
DocuStgned by:
8. Indicate Book and Page where deed or instrument is fled (Use blank page to list additional deeds or
instruments) Book 04683 Page
Book 04016 Page
139
237
Book 18471 Page
Book 35770 Page
368
148
Page I

DocuSign Envelope ID: 91B8B5CB-1896-4C11-BC73-DBCBF9ICECD6
Name: lt>WWtiJlt6lmmftlft#WCJlturxihITM(Parcel 089oazol�
Address: 700 West Sugar Creek Rd, Charlotte, NC 28213
Telephone:
Email Addi
Signature: _
Fax:
(Area Code) (Area Code)
®[e-mail]
Name: Nilayfie0dAWrtor®1t2A#f XPAMdi RG4207) 1• l
Address: 28217
Telephone:
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Signature:
Fax:
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DocuSign Envelope ID: 91B8B5CB-1896-4C11-BC73-DBCBF910ECD6
Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Dreamkey Partners
Address: 4601 Charlotte Park Drive, Suite 350, Charlotte, NC 28217
Telephone: [phone] Fax:
(Area Code)
Email Address: [e-mail]
(Area Code)
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Dreamkey Partners
4601 Charlotte Park Drive, Suite 350, Charlotte, NC 28217
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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
ft)ncially responsible company or entity, if not an individual.)
Printed Name Title
S 4 ZI
SignatureA _ Date
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of J%V^WjVVUrV
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appeared before me this day and under oath
Witness my hand and not al, this
Notary Signature: _
My Commission expires:
ASHTON N SLATE
NOTARY PUBLIC
Mecklenburg County
North Carolina
My Commission Expires March 18, 2022
a NotaryPublicof the County
State of k_____6047w- N" hereby
personally
that this forn vas executed by him her.
day of +. 20 Z f
20-� 7,--
•
CHARLOTTE.
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: 704!336-6692 Fax: 704i336-6586
http://Iandpermits.charmeck.org
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