NCC220805_FRO Submitted_20220218

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: Nexus 485 - Salome Church Road
2. Address of land disturbing activity: 1811-2105 Salome Church Road
3. Approximate date land -disturbing activity will commence. April 2 2018
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential Multi -Family
5. Approximate acreage of land to be disturbed or uncovered: 17.63 Ac.
6. List total site acreage: 21.143 Ac.
7. Landowners of Record (Use blank page to Iist additional owners):
Name: BRC Salome Church, LLC
Address: 5826 Samet Drive, Suite 105
High Point, NC 27265
Telephone: [phone]
(Area Code)
Email Address: _ [e-mail]
Signature:
Name: DRP Stoney Creek, LLC
Address: 5826 Samet Drive, Suite 105
High Point, NC 27265
Fax: [phone]
(Area Code)
Telephone: [phone]QO Fax: [phone]
(Area Code) (Area Code)
Email Add
Signature:
Z5. indicate Book and Page where deed or instrument is tiled (Use blank page to list additional deeds or
instruments) Book 30702 Page 41
Book 15549 Page 762
Book 19841 Page 28
Book 19841
Page 32
Book 19841 Page 37
Book 31495 Page 711 Page l

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: BRC Salome Church, PLC
Address: 5826 Samet Drive, Suite 1 C5
Hiah Point, NC 27265
Telephone:__t336)_889-1500 Fax: [phone]
(Area Code) (Area Code)
Email Address: [e-mail]
2, North Carolina agent, for the person or firm who is financially responsible:
Person or
Address:
Telephone. Fax:
(Area Code)
Email Address:
(Area Code)
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.)
ChristopherT. Dunbar Man;
Printed Name
Title
Signature
I,
Of
certify that
Dafe
a�,�'Notary Public of the County
State of 0 U 11r�_ hereby
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this
Notary Signature:
f` day of d' &-n-b -el
My Commission expires:'
OFFICIAL SEAL
1 ?r Notary Public,
North Carolina
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,,f �„.;"JTY DF fiOCKINGHANi
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My Commission Expires
ENGINEEMN6&ROPWY
MANAOEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpermits.charmeck.org
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