NCC221050_FRO Submitted_20220315

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 parry 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: _Tanoak Single -Family Residential
2. Address of land —disturbing activity: 1065 Homestead Glen Blvd, Charlotte, NC 28214
3 Approximate date land -disturbing activity will commence
December 1
2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered:
6. List total site acreage: ±22.13 AC
15.7 AC
7. Landowners of Record (Use blank page to list additional owners)
Name: Praetorian of Charlotte, LLC
Address
838 S Parker Dr, Florence, SC 29501
Telephone:_
Email Address
701-418-5100
(Area Code)
[e-mail]
Signature:Dni
Name:
Address:
Fax:
n/a
(Area Code)
Telephone: Fax:
(Area Code) (Area Code)
Email
Signature:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 26953 Page 986 Book 25966 Page 830
Book o8569 Page 7-,9 Book Page
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Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Homestead Glen, LLC c/o Cardinal Development Group, LLC - Charles Kieler
Address: 8320 Judy Witt Ln, Vienna, VA 22182
Telephone:_ 571-239-0615 tax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or finn who is financially responsible:
Person or Firm: Bohler Engineering NC, PLLC
Address: 1927 S. Tryon Street, Suite 310, Charlotte, NC 28203
Telephone: [phone] Fax: [phone]
(Area Code) (Area Code)
Email Address: dhines bohleren .com
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.)
Printed Name
Signature
I,
Of'
certify that _
G tf Pr(z t,2 S
Title
June 18, 2021
Date
State of 4FL_0 (u 6 hereby
C L C versonar2y
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and no m W f his ( � day of V �' 20 4
Notary Signature.
My Commission expires
Notary PuB-
YcMe or Honda
CommH GG984030
Expires S/4/2024
CHARLOTTE_
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://landperraits.charmeck.org
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