NCC220239_FRO Submitted_20220112

City of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity on one or more acres as covered by Chapter 17 of the Charlotte
City Code of Ordinances before this form and an acceptable erosion and sedimentation control plan have been completed
and approved by the City of Charlotte. The financially responsible 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. All relevant
items on this form must be filled out accurately and completely
PART A
1. Project name:
Tryon Station
Please Type or Print
2. Address of land -disturbing activity: 7521 Twitter Lane, Charlotte, NC 28213
3. Approximate date land -disturbing activity will commence: 01 14 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Total acreage of land to be disturbed or uncovered: 6.1
6. List total site acreage: 4.9
7. Landowners of Record (attach accompanied page to list additional owners). If the landowner of record is not
the person(s) or firm(s) financially responsible as listed in Part B, item 1, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
Name: SR University LLC
Address: 4 West Oak Ln. STE. 325, White Plains, NY 10604
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: dsmolev sr -re .com (Douglas Smolev
Name:
Address:
Telephone: Fax:
(Area Code)
Email Address:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 34914 page 689 Book Page
Book Page Book Page
Page I

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity (Note: tf the frnancia11 responsible
person(s) or firms) has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: SR University, LLC
Address: 4 West Oak Ln. STE. 325 White Plains NY 10604
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail] (Douglas Smolev)
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina agent:
Person or Firm: Kimley-Horn and Associates
Address: 200. S. Tryon Street Suite 200, Charlotte, NC 28202
Telephone: [phone] Fax.
(Area Code)) (Area Code)
Email Address: [e-mail]
I 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.)
2�)
Printed
Si
Title
Date
1, I — ha_ Owrh ne-Z a Notary Public of the County
S State of U hereby
l
certify
,j
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand ap
Notary Signature:
My Commission ex,
zo62 'A
TRISHA MARTINEZ
NOTARY PUBLIC -STATE OF NEW YORK
No. 01 MA6331843
Qualified in Dutchess County
MY Commission Expires 10-1 g_2023
charlottenc.gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
http:iicharlottene.govideveloi)mentcenter
Rev. 09/2021
Page 2