NCC222705_FRO Submitted_20220810

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 Mecklenburg County Land Development Services. The financial responsibility parry will be on record as the parry 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: Statesville Oaklawn Subdivision
2. Address of land —disturbing activity: 813 Oaklawn Avenue, Charlotte, NC 28206 (corner of Statesville Ave & Oaklawn Ave)
3. Approximate date land -disturbing activity will commence: April
Month
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Mixed use
5. Approximate acreage of land to be disturbed or uncovered: +1- 2.75 AC
6. List total site acreage: +/- 7.20 AC
7. Landowners of Record (Use blank page to list additional owners):
Name: TDC Greenville LLC
Day
2020
Year
Address: 1914 Brunswick Ave, Charlotte,NC 28207
TeIephon L t i ` 6 3 3.2 x
(Area Code) f ( rea Code) c
Email Address: •GS ces/c=�4)1
"2
Signature:
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 22654 Page 801 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: TDC Greenville LLC
Address: 1914 Brunswick Ave. Charlotte= 28207
Charlotte. NC 28207
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: bobby Ctdcrealestate.corn>
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
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 ;noktan in ividual.)
Printed Name Title
4Z
{
Signature Da e
1, 'f t�'l o N a Notary Public of the County
Of Yid ?_;;0LC_)6 LAI20I State of f3oe 0 -- A hereby
certify that AuQ 0KI ' 1 • personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and n ari l seal, this � �5 day of 0 rb(�-, .Teg� 20 19
Notary Signature:
My Commission expi
cmi
ENGRIEB WG a PROM"
MAMGEMEMr
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:[phone] Fax: [phone]
http: //Iandpermits.charmeck. org
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