NCC220734_FRO Submitted_20220214

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name: NCDOT STIP U-5905, Lakeview Road Improvements
2. Location of land -disturbing activity: County: Mecklenburg City or Township: City of Charlotte
Highway/Street: Lakeview Road From: Latitude: 35°20'0.77"N Longitude: 80°51'2.64"W
To: Latitude: 35020'20.00"N Longitude: 80051'27.40"W
3. Approximate date land -disturbing activity will commence: November 16, 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Roadway Widening
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.59 Acres
6. Amount of fee enclosed: $390.00. The application fee of $65.00 per acre (rounded up to the next acre)
is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mackenzie (Zimmerman) Nowacki E-mail Address Mackenzie. Zimmerman(aci.charlotte. nc.us
Telephone [phone] Cell # 704-614-6155 Fax # [phone]
9. Landowner(s) of Record (see accompanied page for a list of all owners):
Name Telephone
Current Mailing Address
City State
119437.90 on
Current Street Address
Zip City
State
Fax Number
Zip
Page No. Provide a copy of the most current deed.
1. Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Mackenzie Nowacki / City of Charlotte
Name
600 East Fourth Street
Current Mailing Address
Charlotte, NC 28202
City State
Mackenzie. Zimmerman(o)-ci.charlotte. nc. us
E-mail Address
600 East Fourth Street
Current Street Address
Charlotte NC 28202
Zip City State
Telephone [phone] Fax Number 704-336-4554
Zip

2, (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone.
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Telephone
State
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Type or print name Title or Authority -°
Signature Date
t�� a Notary Public of the County of f v�Geclt&J
State of North Carolina, hereby certify that ,���C �, appea
personally before me this day and being duly sworn ack owledged that the above form was executed
by him. /,
Witness my hand and notarial seal, this ® day of /� � , 20 2­0
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