NCC223097_FRO Submitted_20220901

City of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity on one or more acres as covered by Chapter 17 of the Charlotte
City Code of Ordinances before this form and an acceptable erosion and sedimentation control plan have been completed
and approved by the City of Charlotte. The financially responsible 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. All relevant
items on this form must be filled out accurately and completely
Please Type or Print
PART A
1. Project name: SELWYN WALK
2. Address of land —disturbing activity: 3100 SELWYN AVE, CHARLOTTE NC 28209
3. Approximate date land -disturbing activity will commence: 03 01 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Total acreage of land to be disturbed or uncovered: 2.0 ac
6. List total site acreage: 1.74 ac
7. Landowners of Record (attach accompanied page to list additional owners). If the landowner of record is not
the person(s) or firm(s) financially responsible as listed in Part B, item 1, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
Name: SELWYN METHODIST PROJECT, LLC
Address: 1300 BAXTER ST. SUITE 370
Telephone: [phone] Fax:
(Area Code)
Email Address:[e-mail]
Name:
Address:
Telephone:
(Area Code)
Email Address:
ax:
Charlotte, NC 28204
(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 36866 Page 185 Book Page
Book Page Book Page
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity(Note: /f the financially responsible
person(s) or firm(s) has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: Methodist Selwyn Project LLC
Address: 1300 Baxter Street Suite 370 Charlotte, NC 28204
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address. [e-mail]
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina agent:
Person or Firm:
Address:
Telephone:
(Area Code)
Email Address:
ax:
(Area Code)
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.)
ROYDEN L. GOODE II MANAGER
Printed a Title
!I� .?,,2 2
ignature Date
1, r e e- Ls a Notary Public of the County
ofSQc.k-tenlnwrq State of a �+- hereby
certify that e. � ersonally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this 3 r� day of 20 2-2—
Notary Signature:
My Commission expires: o — �(
• []=:EWEE8
PKYPUBLIC
charlottenc.gov
Storm Water Services -- Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
http:llcliarlottenc.izovi'developmentcenter
Rev 0912021 Page 2

CITY OF CHARLOTTE - PLANNING DEPARTMENT
SUBDIVISION APPLICATION SIGNATURE FORM
Project Name:
SELWYN WALK
APPLICANT INFORMATION*: (Owner of Record or Owner's Duly Authorized Agent)
Property Owner of Record: SELWYN METHODIST PROJECT, LLC
1300 BAXTER ST. SUITE 370 CHARLOTTE, NC 28204
Applicant Name:
ROYDEN L. GOODE II Contact Name: THOMAS GOODE
Applicant Signature (s)*:
Date: 12/21/2021
Email Address: [e-mail] phone #: [phone]
*lf applicant's signature is not property owner of record, documentation must be uploaded for an authorized
agent signature.