NCC223885_FRO Submitted_20221121

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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: Clear Creek Crossings - Early Grading Package
2. Address of land -disturbing activity: 12809 & 12901 Albemarle Road, Charlotte, NC 28227
3. Approximate date land -disturbing activity will commence: 11
Month
4. Purpose of Development (Residential, Commercial, Industrial, etc.):
Total acreage of land to be disturbed or uncovered: 15 acres
6. List total site acreage: 11.24 acres
01
Day
Commercial
2022
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: Clear Creek Crossings, LLC
Address: 630 S MAITLAND AVE STE 100
MAITLAND FL 32751
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Name: Jerry N Helms
Address: 8509 Corolla Ln, Charlotte, NC 28277
Telephone: Brian Helms - 704.258.8804 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 37259 Page 639 Book Page
Book 37259 Page 650 Book Page
Page 1

Confirrnue - Financial Respolr Mbffity/Ownerrship 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: Clear Creek Crossings, LLC
Address: 630 S MAITLAND AVE STE 100 1 MAITLAND FL 32751
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: Ryan P. Stahl
Address: 12809 Albemarle Road
Charlotte, NC 28215
Telephone: [phone]
Fax:
(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.)
Ryan P. Stahl
Printed N
Signature
I,
Kr►_s h h o-nAe s
Manager
Title
Of 0 r 2Yl j& , State of V r O r l C1 cz.
Date
a Notary Public of the County
, hereby
certify that Ryan P. Stahl as Manager of Clear Creek Crossings, LLC personally
appeared before me this day and tinder oath acknowledge that this
form was executed by him/her.
Witness my hand andlnoparial seal, th' � day of Vc* to � 20 0- �-
Notary Signature:
My Commission ex
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KRISTIN BANKS
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CommisslonNGG339771
Expires May 29, 2023
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charlottenc.gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
http://charlottenc. g_ov/developmentcenter
Page 2
Rev. 09/2021