NCC222285_FRO Submitted_20220725

City of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
FinancialResponsibility/Ownership Form
No person shall iniflate any land -disturbing activity on oneZ or inon, acres as Covered by Chapter 17 of the Chwlotte
City Code of Ordinance befbree this form and an acceptable erosion and sedimentation control plan have been completed
and approved by the City of harl&tte, The f nanciMly ble party will be on record as the paity to accept any Notices
of Violation or related decuments for any noi)<* plhI nee of the City of Charlotte Soil Erosion and Sedimentatlon
Ordinance. If the fingbeWly responWble party is out of State, a itiorih Cirolina agent must be assigned. All relevant
hems on this form mum he filled oat acckffSkly and completely
Please 'll pi-, or Print
PART A
l , Project name: UNPOIN'TE AT PROVIDEANCE
2. Address of lard —disturbing aetivity, 10523 PROVIDENCE RD. WEST, CHARLOTTE, NC 28277
3. Approximate date Iand-di sturbing activity will Commence; ApJ124, 2022
hfontl Day Year
4. Purpose of Developrntat (residential, Dmrneicial, lndustdal, t .: RESIDENTIAL
TYA'L
5. Total acreage of land to be diqurbed or isncoveired: ±0.94
6, Litt total sits acreage; tM
7, Landowners of Reooi-d {attach accompanied page to list additional ownei-8, If the landowner of record is not
the pei-sons) or ft•rn(s) Fnancially responsible as Ilsttd in hart B, item 1, a separate letter of consent signed
by the landowner of record or the iv authorised agent is required:
T7ame: RX 14ABALLANTYNE,LL .
Andress: 800 NORT14 COLLEGE ST., CHARLOTTE, N8206
Tell phone; 704-331-9744; (m) 704-804-342.7 Fax;
(Area Code) (Area Coda)
Email Address: kathiyft @ richa_com
Name-
Address-
Te4horie: Fax'
Area Code)
Email Address:
(Area Coda)
S. Indicate Book and Pap wheve, deed or insfruinent is filed (Use bunk page to list additional deeds or
instruments) Book 2 963 Page 488 Book Page
Book 36851 Page 614 _ Book Page
P'lga 1

Continue - Financial ResponsibilYty/Ownersbip Form
PART H
1. Persons) or firm(s) f naneially responsible fbr this I and-d i stus7bing acti-vity W-gte; Irhe a cia ly �vs,or r r=e
pe);sorr(s) -fr`rw(s) ,has at? aw-01-sfaie a",ess; a Morth Cafvhna agent must be iesigrrweri to win .2 bolow),
Person or FioTn. RICHA B ALLAINTYNE, LL . (KATHR'YN ROHERA)
Address: 800 NORTH COLLEGE SM, CHARLOTTE, NYC 28 06
Telephone: 704-33_I-9744, (m) 704-804-34 7 lax:
(Area Code) Erin ail Address: kathryn richa_com
(Are(t Cade}
2. If the FimneialIy Respow,.ibic Party 1s not a resident of North CaroIina, give name and strut address of the
designated Noilh Carolina agtjit:
Person or Firm
Addres s:
Telephone: Fax:
(Area Cede)
Email Address.
(Area Cods)
3. The above, irifor'mation is true wind corroet to the best of my knowledge, and &,lief and was provided by mc-
,whi le under• oath. (This'f'nim must be. signed by the financially responsible person if an individual or by an
officer, director, partner, ariorney-in- fact, or other person with authat ity to execute instrurnants for the
financially iispongib ie company or entity, if not an individual,}
Kathryn Rohcra
PxintedName kAqVAA
signature
VP
Title
04.' 19/2122
Date
_r, Manobar Iyionichandani a A�ofaiy Public of the Cowfy
of harforie : gate of Ni011h Carolina , hereby
cerfify friar., Kathryn Rohera Mrsonally
appeared before ine this day and under oath acknowledge #tat fhifb1•rr; ivz executed by hiin1 rer_
kl INess my hard and naoriul seal this
My arrirrt�s,gwn expires, �] 1�4r��2�
of- AP l
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chartottenc,gov
tone WaAtr Services — Land Development
600 East Fourth Street, Chadotte, Nwth Carolina 2 B202-2844
Tdtphonc, 7041336-602
h�t�'J{����Eorter�c.�:�vid��e�o�or�entc�a�ter
Rev. 13�Ff2021
Page 2