NCC221726_FRO Submitted_20220504

City of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity on one or more acres as covered by Chapter 17 of the Charlotte
City Code of Ordinances before this form and an acceptable erosion and sedimentation control plan have been completed
and approved by the City of Charlotte. The financially responsible 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. All relevant
items on this form must be filled out accurately and completely
Please Type or Print
PART A
1. Project name: 8 02H L i n GE o Loi Ve
2. Address of land -disturbing activity:9jO2y L t nc(4 L o Ke, T-) r. C h o Yl b- -+c , N C
3. Approximate date land -disturbing activity will commence: O `"I Z01 2 2
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): �� C ► Gt iJirl A
5. Total acreage of land to be disturbed or uncovered:-
b. List total site acreage: 2. 2
7. Landowners of Record (attach accompanied page to list additional owners). If the landowner of record is not
the person(s) or firms) financially responsible as listed in Part B, item I, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
Name: Co►Y I l+ n a Ph p f, S l t — --
Address: I (J I2 SC A-trt p All Gt W a'i it Q V (, N L
Telephone: —30U i 0 ( 0H 9 Fax:
(Area Code) (Area Code)
Email Address: V b. M V- d Y`rl a 0 t9 A W a2 1, L O►Y►
Name:
Address:
Telephone:
(Area Code)
Email Address:
Fax:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book ; Lp2 Zq Page 2 8 i Book Page
Book Page Book Page

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or finn(s) financially responsible for this land -disturbing activity (Note: ljrhefinancrally respoanble
person(s) or firms) has an oul-of-slate address, a Norrh Carolina agent must be designated in item 2 below):
Person or jirrtj;V�
Address:
1lL
Telephone: Fax:
(Area Code) (Area Code)
Email Address: vb.rllyecAmoin*tl.Com
2. If the Financially Responsible Parry is not a resident of North Carolina, give name and street address of the
designated North Carolina agent:
Person or Firm:
Address:
Telephone: Fax:
(Area Code} (Area Code)
Email Address:
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.)
Do n t 1 rm�Ittn G-cn:eXotI C0ntravhr _
Printed Name Title
U
51gil-ature bate
I, binl vidsm a Notary Public of the County
V Kuwm State of hereby
certhp that h I
appeared before me this day and under oath acknowledge that this.f arm was executed by him/her.
Witness my hand and no urial seal, this day of J + l 1 [ . 202-2—
Notary Signature: �T
My Commission expires: 1 2
• Lindsey Davidson
NOTARY PUBLIC
Rowan County NC
My Commission Expires August 12, 2023
charlottenc.gov
Storrs Water Service,, Land Development
600 East Fourth Street, Charlotte. North Carolina 28202-2844
Telephone: [phone]
hitp: /lcharlottenc. pv/developmen tcenter
Rev. 09 202 t �'•