NCC224053_FRO Submitted_20221209

-• •, �-
111111141-411111 ir, a, 0 � 4. ZIAIWAQ
person may initiate any land -disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/or fax information
unavailable, place N/A in the blank.)
1. Project Name Hidden Valley Firehouse No.45
2.
3.
4.
Location of land -disturbing activity: County Mecklenburg City or Township
Charlotte
Highway/Street 5800 N Tryon St Latitude 35.2653 Longitude -80.7689
Approximate date land -disturbing activity will commence: January 1, 2023
Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
2.21 ac
6. Amount of fee enclosed: $ 300.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bruce Miller
Telephone [phone] Cell #
E-mail Address [e-mail]
Fax
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Charlotte
Name
600 East 4th Street
Current Mailing Address
Charlotte, NC 28202
City
State Zip
704-907-6806
Telephone
Current Street Address
Fax Number
City State Zip
10. Deed Book No. 35978 Page No. 159 Provide a copy of the most current deed.
Part B.
Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
City of Charlotte
Name
600 East 4th Street
Current Mailing Address
Charlotte, NC 28202
City State Zip
[e-mail]
E-mail Address
(same)
Current Street Address
City
State
0

Telephone [phone] Fax Number.
( If the Financially Responsible Party is not a resident of North Carolina, give name and street address
the-de,Lsignated North Carolina Agent: z
Name
Current Mailing Address
City
T
E-mail Address
Current Street Address
State 'N"' zip city
Fax Nu
State Zip
(b) If the Financially Responsible Party is Pa kfersWkor other person engaging in business under an
e Ce d Name. If the Financially Responsible Party
ess of the Re listed rti� 'ft
assumed name, attach a copy of the 0 fj to of Assu
is a Corporation, give name and street a listed d Agent:
I
Name of Registered Agent
Current Mailing A e ss
City Z State
E-mail Address
Current Street Address
N.,
Zip city State zip
Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Bruce Miller
Type or print name
'Signature
City of Charlotte- Sr Project Manager
Title or Authority
Date
1, CI L"'w a Notary Public of the County of Vkc L_4*-�
�, State of North Carolina, hereby certify that '(_ULL k appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this day of 3 �t L 20
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