NCC223584_FRO Submitted_20221107

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: The Pearl: Charlotte Innovation District
Design Package D-4.1 Master Infrastructure Phase IA
2. Address of land -disturbing activity: 801 S McDowell St, Charlotte, NC 28203
3. Approximate date land -disturbing activity will commence: 10 15 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial
5. Total acreage of land to be disturbed or uncovered: 19
6. List total site acreage: 19
7. Landownefs 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: Charlotte Mecklenburg Hospital Authority
Address: PO Box 36022, Charlotte, NC 28236
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Parcel ID
Owner
Legal Reference
12517303
RR Assemblage LLC
36885-573
M20155
Charlotte Mecklenburg Hospital Authrori
09215-225
M20154
Charlotte Mecklenburg Hospital Authrority
14356-56
32520150
Lookout NC Properties, LLC
35267-192
M20158
Lookout NC Properties, LLC
35267-197
M20105
LBAcquistions,LLC
35709-403
12517311
Duke Power Company
06306-042
12517518 inuke
Power Company
06306-042
12517313
Duke Power Company
06019-516
Email Address:
x:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book See Above Page See Above Book Page
Book Page Book Page
Page I

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity ote: 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: Charlotte Mecklenburg Hospital Authority
Address: 1300 Blythe Blvd, Charlotte, NC 28203
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 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.)
Amanda Mewborn
Vice President, Planning Design, Construction
Title
jto(6I2zZZ
Date
I, L-NAMPAY-- CttTN &'0 4-1 a Notary Public of the County
Of— M C. C t' S `1 R..Cw , State of hereby
certify that M kN t' k GAk k.- WV_- W $a R-N 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,
Notary Signature:
My Commission expires:
Rev. 09/2021
�7e B 2, 20 210
;m day of 20 2Z
Champak
•1 Meeklenburg County, NC
My Commission Expires FE.a Z, 2-0
charlottenc.gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
littp://charlottenc.gov/develoi)mentcente
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