NCC215258_FRO Submitted (Recovered)_20210916

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Farm
No person shall initiate any land -disturbing activity covered by Chapter 17, Article 2 of the Charlotte Citv 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.
PART A Please Type or Print
I. Project where land -disturbing activity is to be undertaken:
The Home Depot #3639 - Charlotte, NC Parking Lot Pavement Project
2. Address of land -disturbing activity:
9501 Albemarle Rd., Charlotte, NC 28227
3. Approximate date land -disturbing activity will commence: August 23rd 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial Parking Maintenance
5. Approximate acreage of land to be disturbed or uncovered: 2.71 ac
6. List total site acreage: 10.1 ac
7. Landowners of Record (Use blank page to list additional owners):
Name: Home Depot USA Inc.
Address: 2455 Paces Ferrer Rd.
Atlanta, GA 30339-4024
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: david kazero depot . com
Signature:
Name:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Boom 11074 Page 3 0 n Book Page
Book Page Book Page
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: The Home Depot USA, Inc. - David Kazerooni
Address: 2455 Paces Ferry Rd.
Atlanta, GA 30339-4024
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: david_kazerooni@homedepot . com
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: The Home Depot USA, Inc. - Thomas Hedrick
Address: 9501 Albemarle Rd.
Charlotte, NC 28227
Telephone: 7 04 - 53 5 - 6 9 82 Fax:
(Area Code) (Area Code)
Email Address: thomas [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
financially responsible company or entity, if not an individual.)
David Kaz
Printed Name
I, lvelisse Guadalupe
Of Dekalb
certifiJ that David Kazerooni
56_11 i L)
Title
Date
a Notary Public of the Count,
State of Georgia herebv
appeared before me this day and under oath acknowledge that this form was executed by him, her.
Witness my hand and n-otarll\/RI�1}jlal seal, this �� /10th dm, o f_ September
NVtaty A4 �,natlRl �. �J • 1\�{(d 111111/
7 , ,`�%!! EOF•'- Notem Public. GeorgiaPE
My Commission expires: March 0 23 MV Marci;0'8`0i0'2x3 `°'
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 Fast Fourth Street, %'nariotte, North Carolina 28202- 844
Telephone: [phone] Fax: [phone]
http://Iaiidpeffnits.chamieck-.org
personally
20 21
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