NCC223558_FRO Submitted_20221017

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
PART A
1. Project name:
Please Type or Print
Arrowood Kiddie Academy
2. Address of land -disturbing activity: 3512 W Arrowood Road, Charlotte NC 28273
3. Approximate date land -disturbing activity will commence: September 1, 2022
Month Day
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial
5. Total acreage of land to be disturbed or uncovered: Commercial
6. List total site acreage: 1.6 acres
Year
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: Karma Real Estate, LLC
5625 Fairview Road, Charlotte NC 28209
Telephone: [phone] Fax: [phone]
(Area Code) (Area Code)
Email Address: [e-mail]
Name: R. Chris Thomas
Address: 301 S. College Street, Suite 2800
Charlotte, NC 28202
Telephone: [phone] Fax: [phone]
(Area Code) (Area Code)
Email Address: [e-mail]
S. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 33970 Page 938
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: Ifthe financially responsible
person(s) or frrm(s) has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: MSD2 Arrowood LLC
Address: 155 First Street - Suite 104
Mineola, NY 11501
Telephone: [phone] Fax
(Area Code)
Email Address: mambrosino(@_ambrosinocorp.com
516-284-0411
(Area Code)
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: R. Chris Thomas
Address: 301 S. College Street, Suite 2800
Charlotte, NIC 28202
Telephone: [phone] Fax: [phone]
(Area Code) (Area Code)
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.)
R C14n4s 14wAs AIXIAVaA;;�o AWir
Printed Name Title
Signature Date
1 Le,wttl S . D(I~ rna nJ a Notary Public of the County
of Mbc*Vn_E?AA2� State Of—" c-4Ai21 inci. hereby
certify that R. GhnSTlionn" personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this 3rd day of O(,�}D bl5P 20 oq vA
Notary Signature: �IO�a
My Commission expires: at 1,5.006?B
Jq Notary Public �
T Mecklenburg 0 s
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County
_ My Comm. �r��.
charlottenc.gov ,,9T/y C A i
Storm Water Services — Land Development �ftr111n1s+O++
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
http://charlottenc.gov/developmentcenter
Rev. 09/2021 Page 2