NCC222090_FRO Submitted_20220604

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 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:
Bradford Preparatory School Athletic Field Expansion
2. Address of laud —disturbing activity: 2502 Salome Church Road Charlotte, NC 28262
3. Approximate date land -disturbing activity will commence: March 15 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered
6. List total site acreage: 69.1
7. Landowners of Record (Use blank page to list additional owners):
Name: BPS Bears, LLC
Address: 2502 Salome Church Road Charlotte, NC 28262
Telephone: [phone] _ Fax:
(Area Code)
Email Add
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 34704 Page 484 Book Page
Book Page Book Page
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Continue - Financial Responsibility/Ownership Form
PART E
1. Person(s) or firms) financially responsible for this land -disturbing activity:
Person or Firm: Hubrich Contracting. Inc.
Address: 4321 Medical Park Drive Ste. 100 Durham. NC 2770
Telephone: [phone] Fax:
(Area Code)
Email Address: steve(d)hubrichcontractina.com
(Area Code)
2. North Carolina agent: for the person or firm who is financially responsible:
Person or Firm: Hubrich Contracting, Inc.
Address: 4321 Medical Park Drive Ste. 100 Durham. NC 2770
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: steve@a ubricheontracting_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.)
I
Of
certify that X/,, /: r, u
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State of r
Director of Operations / Head of School
Title
1 /24/22
Date
a Notary Public of the County
nl' hereby
appeared before me this day and under oath acknowlea?ge that this form was executed by himlher.
Witness my hand and notarial seal, this
Notary
My Commis ' xpires:
day of 20 ck —
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MANAGEMEW
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:[phone] Fax: [phone]
http://landpermits.charmeck.or,
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