NCC220901_FRO Submitted_20220322

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 fling 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:
2. Address of land —disturbing activity: 600 SOUTH TRYON
3. Approximate date land -disturbing activity will commence: JANUARY 15, 2011
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): URBAN MIXED USE
5. Approximate acreage of land to be disturbed or uncovered: 1. 6
6. List total site acreage: 1 . 6
7. Landowners of Record (Use blank page to list additional owners):
Name: GSLH CHARLOTTE REALTY HOLDINGS
Address: 4725 PIEDMONT ROW DRIVE, SUITE 800
CHARLOTTE, NC 28210
Telephone: [phone] Fax: [phone]
(Area Code) (Area Code)
Email Address:
Signature:
Name: SCOTT KURZ
Address: 4725 PIEDMONT ROW DR STE 800
CHARLOTTE, NC, 28210
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: Sc;[e-mail]
Signature:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 33050 Page 966 — 969 Book Page
Book Page _ 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: GSLH CHARLOTTE REALTY HOLDINGS
4725 PIEDMONT ROW DRIVE, SUITE 800
CHARLOTTE, NC 28210
Telephone: [phone]
(Area Code)
Email Address:
ax: 704-716-8600
(Area Code)
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
(Area Code)
Email Address:
ax:
(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.)
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Print ;till Title
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Sign a Date
I, V J CNN 3� _ l\A Ai3tV , a Notary Public of the County
of � tJ State of No YLTI-4 u N A hereby
certify that o H &) W — H 4-a-ck S 'T11- personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notar l seal, this 1 Alt of IN 6 Jet �'t3 e�'2 20 �)
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Notary Signature:
My Commission
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(,I IABLOTTE.
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpermits.charmeck.oi-g
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