NCC220256_FRO Submitted_20220118

DocuSign Envelope ID: FOE64F72-BBA6-4DC5-B005-B1 C121 F6D8DE
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: Northwqy at Thorn Bluff
2. Address of land -disturbing activity:7641 / 7637 Thornbluff Road
33. Approximate date land -disturbing activity will commence: 2 1 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5_Approximaate acreage of land to be disturbed or uncovered: 3.5
6_List total site acreage: 7.19
7. Landowners of Record (Use blank page to list additional owners):
Name: Robert Spencer Mooney (7641), Richard Paxton (7641)
Address: 305 Dogwood Street Gastonia NC 28056
Telephone: [phone] (Robert), 980.925 ,3004 (Richard) Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Robert Mooney
Name: Kirk Gillespie (7637)
Richard Paxton
Address: 7637 Thornbluff Road,Charlotte NC 28214
Telephone: [phone] Fax:
(Area Code)
Email Address ,__..,ki.JkRillespi
Signature:iv w.
82DOE3F03C4DE...
(Area Code)
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DocuSign Envelope ID: FOE64F72-BBA6-4DC5-B005-B1 C121 F6D8DE
Continue - Financial Responsibility/Ownership Form
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 08461 Page 343
Book 29237
Page 554.
Book 29237 Page 554
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Northway Homes LLC
Address: 1026JU Street Suite B-145 CharlQtte,NC 28208
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address:
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)
Book _ Page
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.)
Cyrus Moidehi Manager
Printed Name
Signature
Title
Date
I, ,_ . a Notary Public of the County
of State of , hereby
certify that personally
appeared before me this day and under oath acknowledge that this form was executed by himlher:
Witness my hand and notarial seal, this
Notary Signature:
My Commission expires:
day of . 20.
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DocuSign Envelope ID: FOE64F72-BBA6-4DC5-B005-B1 C121 F6D8DE
City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
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Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:7Q4t336-6692 Fax.[phone]
http:lllandpermits_charmeck.org
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