NCC223132_FRO Submitted_20220906

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r � - x Mecklenburg County Soil Erosion and
Sedimentation Control Ordinance
A Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Section 6 of the Mecklenburg
County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to
completing and filing this form with Mecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance with the above Ordinances. 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: Capital Independence
2. Address of land -disturbing activity:
Matthews, NC 28105
10905 E Independence Blvd.
3. Approximate date land -disturbing activity will commence: March
Month
4. Purpose of development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered. 10.488 ac
6. Total site acreage: 10.268 ac
1 2022
Day Year
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: The Leon Levine Foundation
Address: 6000 Fairview Road, Suite 1525
Charlotte, NC 28210
Telephone: [phone]
Email Address:
Owner #2 Name: Chaps Holdings
Address: 17008 Belle Isle Drive
Cornelius, NC 28031
Fax: [phone]
Telephone: [phone] Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 1780 page 333 Book 32979 page 358
Book 7155 page 841 Book Page
(continue on back or separate pages as necessary)
Porni Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Wes Taubel, Two Capital Partners
Address: One Buckhead Plaza, 3060 Peachtree Rd NW, Suite 960
Atlanta, GA 30305
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: CT Corporation System
Address: 160 Mine Lake Court, Suite 200, Raleigh, NC 27615
Telephone: [phone] Fax:
Email Address: [e-mail]
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.)
Wesley G. Taubel
Printed Name
Signature
Manager
Title
09.07.21
Date
1, Y_� Vyl�,bwN CDYW i n , a Notary Public of the
County of _ 1, ,�C.Q , State of cheep rq6 �� , hereby
certify that V V -'� 5 b • personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand a�d notarial seal, this �� day of , 20
Notar� Si
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Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte, NC 28208-5237
Phone [phone]