NCC223736_FRO Submitted_20221103

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.
PART A Please Type or Print
I. Project where land -disturbing activity is to be undertaken: Cleveland Avenue Apartments
2. Address of land —disturbing activity: 2025 Cleveland Ave, Charlotte, NC 28203
3. Approximate date land -disturbing activity will commence:_ August 1 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 1.1 Ac
Arl
List total site acreage: 0.75 Ac
7. Landowners of Record (Use blank page to list additional owners):
Name: JESSE P (REV TRUST) CAMPBELL
Address: 209 McDonald Ave, Charlotte, NC 28203
Telephone:
(Area Code)
Email Address:
Signature:
Name:
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Fax:
Fax:
(Area Code)
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 28217 Page 805 Book Page g
Book Page
Book Page
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Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Abacus Capital
Address: 1200 East Morehead Street, Suite 106, Charlotte, NC 28204
Telephone: [phone]
ax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
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.)
JWy ,A jI.-AtI1k. -tl
Printed Name
IIVG$_� 4-
I,
k7
Of State of
certify that
appeared before me this day and under oath
Witness my hand angl no , rial seal,
Notary Signature:
My Commission expires: � \ OS r 2 Z)
101 y
Title
1 'L I 'b 4
Date
a Notary Public of the County
hereby
personally
that this form was executed by him/her.
day of 1� 20
Amber L Simpson
NOTARY PUBLIC
Mecklenburg County, NC
CHARLOTTE.
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://landpermits.charmeck.org
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