NCC221954_FRO Submitted_20220524

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 Meckienburg 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: "Stax Gym Site"- Kairof LoSo Station
2. Address of land --disturbing activity; Generally located at the addresses of 3722 S Tryon Street & 3600 S Tryon
3. Approximate date land -disturbing activity will commence: .
Month 05 Day 23 Year 2022
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
S. Approximate acreage of land to be disturbed or uncovered: 17.5
6. List total site acreage: 17.35
7. Landowners of Record (Use blank page to list additional owners):
Name: Kairoi Residential
711 Navarro Street, Suite 400, San Antonio, TX 78205
Telephone: [phone] Fax:
(Area Code)
Email Address: [e-mail]
Signature:
Name:
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Fax:
(Area Code)
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 35339 Page 679 Book 35339 Page
Book Page Book Page
Page t

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Hinton Construction Company, LLC.
Address: 110 Dalton 5t _
Shreveport, LA 71006
Telephone:[phone] Fax:
(Area Code) (Area Code)
Email Address: lar![e-mail]
2. North Carolina agent. for the oerson or firm who is financially responsible:
Person or Fi
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.)
Larry McAllister Senior Project Manager
PxintedName _1�11_1111 Title
Date
` c
r a Notary Public of the County
Of State of�'AQLI;�Q C-IN hereby
certify that personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarjtisgal, this day of )X�420 �.�.
Notary Signature: r
My Commission expires:F==
Notary Public
Cabarrus Co., North Carolina
My Commission Expires Aug,10, 2023
CHARLOITL
.GDfEMG i PROPERLY
m1 "BArw
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:[phone] Fax:[phone]
httpJ/Iandpertnits.charmeck.org
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