HomeMy WebLinkAboutNCC230234_FRO Submitted_20230127City 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: Alexan Loso
2. Address of land —disturbing activity: 3305 South Boulevard, 121 Hartford Ave., 139 Hartford Ave
Charlotte, NC 28209 (PIN #:14705111, 14705124, 14705112)
3. Approximate date land -disturbing activity will commence: February
9
15
Month Day
Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Total acreage of land to be disturbed or uncovered: 2.80 Acres
6. List total site acreage: 2.27 Acres
2023
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: CH MF BTH III/CHARLOTTE LOSO LLC
Address: 4509 Creedmoor Road, Suite 308
Raleigh, NC 27612
Telephone: 202-290-0541
Fax:
(Area Code) (Area Code)
Email Address: rbrooks@crowholdings.com
Name:
Address:
Telephone:
(Area Code)
Email Address:
Fax:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book "7644 Page 107 Book 27 Page 158
Book Page 251
Book Page
Page 1
Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity(Note: If the financially responsible
person(s) orftrm(s) has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: CH MF BTH III/CHARLOTTE LOSO LLC
Address: 4509 Creedmoor Road, Suite 308
Raleigh, NC 27612
Telephone: 202-290-0541 Fax:
(Area Code) (Area Code)
Email Address: rbrooks@tcr.com
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:
(Area Code)
Email
ax:
(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.)
Robert Brooks
Printed Name
Signature
Of j l State of
certify that `O 1TA-Ou'ts�w MCDr-C ak
Vice President
Title
tit i✓ .
I9 :23
Date
a Notary Public of the County
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this It day of �_
Notary Signature:
My Commission expires: 01i - 'zf, • V
charlottenc.gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: 704/336-6692
Rev. 09/2021 htgi://charlottenc. eov/develolwnentcente,
20 Z3
ROMMEL SIMON
NOTARY PUBLIC
WAKE COUNTY, NC
MV Commission Ex[ ires 3/28/2024
hereby
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