NCC230213_FRO Submitted_20230125

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 b3 Chapter 17 of the Charlotte
City Code of Ordinances before this form and an acceptable erosion and sedimentation control plan have bcoa completed
and approved by the City of Charlotte. The financially responsible party will be un 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 patty is out of State, a North Carolina agent must be assigned. All relevant
items on this form must be filled out accurately and completely
PART A Please Type or Print
1. Project narne: CIP Whitehall
2_ Address of land -disturbing activity: 2745 Whitehall Park Drive, Charlotte, NC, 28273
3. Approximate date land-disturbuag activity will commence. October 15, 2022
Month Day Year
4. Purpose of Development (Restdential, Commercial, .Industrial, etc.): Commercial
Total acreage of land to be disturbed or uncovered. 4.5 acres
6. List total site acreage. 17.254 acres
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:
Naze: C[P 2014 Whitehall Owner LLC
Address: 19762 MacArthur Blvd, Suite 300, Irvine, CA 92612
Telephone: [phone] Pax: 949-474-21 d 1
(Area Code) (Area Code)
Email Address; ania ci realestate com
Name; NIA
Address:
Telephone: Fax:
(Area Code)
Entail Address:
(.Area Codc)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 30786 Page 535-561 Book Page
g
Book Page Boole Page
Pave I

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity(Note: If the financialhresponsible
person(.) or firm(s) has an out-of-state address, a North Carolina agent must he designated in item 2 below):
Person or Firm: CIP 2014 Whitehall Owner LLC
Address: 19762 MacArthur Blvd, Suite 300, Irvine, CA 92612
Telephone: [phone] Fax: [phone]
(Area Code) (Area Code)
Email Address: ania@ciprealestat_e.com
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina
lina agent: l i
Person or Firm: 4 v 4if D�(Jk Y'I U eat p k& f rb Eew-ViceS
Address: '?,O l BeKI CXia, , Char o +�-_ , M& 2,a21
Telephone:
ax:
(Area Code) (Area Code)
Email Address: i(Y1kiaA (i) 6DreatQ�� aie COM
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.)
Robert Y. Strom
Signature
of
Chairman of the Board
SEE ATTACHED NOTARY PAGE
8/26/2022
Date
a Notary Public of the County
State of hereby
certify that 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 day of . 20
Notary Signature:
My Commission expires:,
SH
cha rlottenc.gov
Storm Water Services — Land Development
600 East Fourth Sheet, Charlotte, North Carolina 28202-2844
Telephone: [phone]
litip:h'cliarlottenc.gov/develoDmentcenter
Rev. 09, 2021 Page 2

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of Orange ) ss
Subscribed and sworn to (or affinned) before me on this 2A, of 2 ,
by S(l�7'111 , proved to me on the ba is of satisfactory evidence
to be the person(s) who appeared before me.
4Da',."'M�y
ANNA PFEIL{Seal} µ Notary Public - California z Signature
`orange CountyCommission 4 2349021
Comm- Expires Mar 24, 2Q2�