NCC223275_FRO Submitted_20220921

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 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:. Townes atLOSO (aka, Old Pineville
Torvnhonies Phase 2
2, Address of land —disturbing activity: 4920 Old Pineville Rd. Bld s. 1-12
3. Approximate date land -disturbing activity will commence: Sept. 2022
Month Day Year
4. Purpose of Development (Residential, Conmiercial, Industrial, etc.): Tot'vnitonae Construction
5. Approximate acreage of land to be disturbed or uncovered: 1.19 ac.
6. List total site acreage: 1.67 ac.
7. Landowners of Record (Use blank page to list additional owners):
Name (1) Boulevard at 4920 Ord Pineville, LLC
Address: 2005 Lombardy Circle
Charlotte NC 28203
Telephone: [phone] Fax: N/A
(Area Code) (Area Code)
Email
Address: nrichael.berrdeif&,blvdrea.cont
Signature: See Prior Authorization Letter from Otvner
Name (2):
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Fax: N/A
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 36511 Page 148 Book Page
Boob Page Book Page
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firni(s) financially responsible for this land -disturbing activity:
Person or Firm: NVR, Irte. /Rvan Homes
Address: 10710 Sikes Place Suite 200
Charlotte NC 28277
Telephone: [phone] Fax: N/A
(Area Code) (Area Code)
Email Address: bscanlinglivrinc,com Brodie Scanlin.
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Corporation Service Coramvan
Address:_ 2626 GlenwoodAyenue, Suite 550
Raleigh, NC 27608
Telephone: [phone] Fax: N/A
(Area Code) (Area Code)
Email Address: N/A
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.)
an R. Hess
Of -..--LMN
certi& that
Vice President
Title
Date
a Notary Public of the County
State of (, hereby
appeared before ine this day and under oath acknowledge that this form ims executed by hire/her.
Personally
Witness my hand and notarial seal, this day of 20 � Q,
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Notary Signature:4 .....-- .......
Y_
My Cortntrission expires:
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Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:[phone] Fay:: 704/336-6586
littp://landpermits.cl)arineck,org
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