NCC223541_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 parry 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: Sugar Creek Mixed Use
2. Address of land —disturbing activity: 4101 Greensboro Street, Charlotte, NC 28206
Approximate date land -disturbing activity will commence:
October 15 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial
Total acreage of land to be disturbed or uncovered: 17.02
6. List total site acreage: 18.33
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: S2K Charlotte QOZB LLC
Address: 5950 Hazeltine National Dr., Suite 305, Orlando, FL 32822
Telephone:
[phone]
Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Name: Sugar Creek Ventures LLC
Address: 1001 Elizabeth Ave, Suite 1 D, Charlotte, NC 28204
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 32865
Page 485
Book Page
Book 36963
Page 879
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: If 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: S2K Charlotte QOZB LLC
Address: 5950 Hazeltine National Drive, Suite 305, Orlando, FL 32822
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 Film: CT Corporation System
Address: 160 Mine Lake Ct Suite 200, Raleigh, NC 27615
Telephone: [phone] 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.)
Neil Cohen
Printed Name
Signature
I Ian Shainbrown
of Essex
certify tl,
Neil Cohen
appeared before me thi
Witness my hand and
Notary Signature:
My Commission expires:
EVP & General Counsel
Title
10/6/21
Date
a Notary Public of the County
State of New Jersey hereby
oath acknowledge that this form was executed by him/her.
this 6th day of October 2022
2023
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
http://charlottenc.gov/developmentcente
Rev. 09/2021 Page 2