NCC222359_FRO Submitted_20220726

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 b 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: Adams Place- Phase II
2. Address of land --disturbing activity: 10250 Revolution Court, Charlotte NC 28262
3. Approximate date land -disturbing activity will commence: March 1 2022
Month Day Year
4. Purpose of Development (Residential, Commercial. Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 4.90 Acres
G. List total site acreage: 5.17 Ac (Phase II), 11.71 (Total Site)
7. Landowners of Record (Use blank page to list additional owners):
Name: Adams Place Properties, LLC
(Area Code) (Area Code)
Email Address: [e-mail]
Signature:
Name: L M v\A_%d SR
Address: �l �'�
vjicmMk V1, NL 2gU —
Telephone: Fax:
(Area Code)
Email Address:
Signature:
(Area Code)
8. Indicate Book and Page where deed or instrument is Bled (Use blank page to list additional deeds or
instruments) Book 31129 Page
Book Page
34
Book Page
Book Page
Page

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or
Address
ce Properties, LLC
��Telephone: [phone] ' Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Ad
Telephone:
ax:
(Area Code) (Area Code)
Email Address:.r tributecom anies.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 individuaI.)
M XV k M AA/,dS r. M Alt,. e �
Printed Name Title
Signature
al 13 z1
Date
I, Q=0�_'aa Notary Public of the County
Of
certify that
State of y hereby
appeared before me this day and under oath acknowledge that this form was executed by himther.
personally
Witness n y hand and notarial seal, this
Notary Signature:
My Commission expires:
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Land Development Division °°I [)V ER G e`11
600 East Fourth Street, Charlotte, North Carolina 28202-2844 411111111 00
Telephone: [phone] Fax:[phone]
hUp://Iandpermits.charrneek.org
cmi
ENGINEERING $ PROPERTY
MANAGEMENT
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