NCC222144_FRO Submitted_20220609

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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: Shopton Road West Residential
2. Address of land —disturbing activity: 11110 Island Point Road, Charlotte, NC 28278
3. Approximate date land -disturbing activity will commence: January 1 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 22.30
6. List total site acreage
27.28
7. Landowners of Record (Use blank page to list additional owners):
Name: William C Hedrick JR
Address: 60190ak Ridge CT
Matthews, NC 28104
Telephone: [phone]
Fax:
in, fl_Aa � (Area Code)
Email Address: [e-mail]
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Name:
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Fax:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 02314 Page 236 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: M/I Homes of Charlotte, LLC
Address: 5350 77 Center Drive, Suite #100
NC 28217
Telephone: ( 704) 597-4524 Fax:
(Area Code)
Email Address:
(Area Code)
2_ North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Jeremia Murnh
Address: 5350 77 Center Drive, Suite 9100
Charlotte, NC 28217
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address:_ _jmurphy(d),mihomes.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.)
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Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:[phone] Fax:704t336-6586
http:lllandpermits.charmeck.org
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