NCC223136_FRO Submitted_20220909

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: Ballantyne Senior Affordable
2. Address of land —disturbing activity: 15217 Ballancroft PY Charlotte, NC 28277
Approximate date land -disturbing activity will commence: OCT
Month
4. Purpose of Development (Residential, Commercial, Industrial, etc.):
5. Total acreage of land to be disturbed or uncovered: 1.57
6. List total site acreage: 1_57
10 2022
Day Year
Residential - Multifamily
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: CC Ballantyne LLC
601 S. Tryon St., Ste. 800, Charlotte, NC 28208
Signature:
Telephone: ���" �2(-(0(�l� _Fax:
(Area Code) (Area Code)
Email Address: I=IM A J 00 ✓Y1 1 A A C r�$GG(1 COyh r1nv,� i'l-► e S. dJfv�
Name:
Address:
Telephone:_ Fax:
(Area Code) (Area Code)
Email Address:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 36759 page 282 Book Page
Book 36759 Page278 Book Page
Page I

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity Note: If the financially responsible
person(s) orfirm(s) has an out-of-state address, allorth Carolina agent must be designated in item 2 below):
Person or Firm: Ballantyne Seniors, LLC
Address: 2132 Thrift Road Suite A, Charlotte, NC 28208
Telephone: (1U4)sy/-ubsu 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: _ _Fax:
(Area Code)
Email Address:
(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.)
Ballantyne Seniors, LLC By: LSR Ballantyne Seniors, LLC, its managing member Byy �� LSR Manager LLC, its managing member
Lee M. Cochran V ice President
Printed Name
Title
3/1/2022
Signature Date
Sue S Moody
of Mecklenburg
certify that Lee M.
appeared before me this day and under oath acknowledge
Witness my hand and notaria this c
Notary Signature: _
My Commission expires: 03/26/2022
Rev. 09/2021
State of North Carolina
a Notary Public of the County
. hereby
form was executed by him/her.
March 2022
charlottenc.gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
httl2:Hcharlottenc.gov/develo2mentcenter
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