NCC230506_FRO Submitted_20230228

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: Story University North
2. Address of land —disturbing activity: 3800 Morehead Road, Charlotte, NC (PID# 02954103),
& minor grading on PID# 02954106 and 125 Floyd Smith Office Park Dr 140, Charlotte, NC (PID# 02954105)
3. Approximate date land -disturbing activity will commence: March 1, 2023
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Total acreage of land to be disturbed or uncovered: 21.2 AC +/-
6. List total site acreage:
25.0 AC
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
UNorth Project Owner, LLC
Address: 39 Georgia Ave SE, Suite 200
Atlanta, GA 30312
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Name: Doma Vida Investments, LLC
Address: 602 E. Morehead St.
Charlotte, NC 28202
Telephone: 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 12361 Page 859 Book Page
Book 37377 Page 922 Book Page
Pal;c 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(v) orfrrnn(s) has an out -of --state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: UNorth Project Owner, LLC
Address: 39 Georgia Ave SE, Suite 200
Atlanta, GA 30312
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: Cogency Global Inc.
Address: 212 South Tryon Street, Suite 1000
Charlotte, NC 28281
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.)
Jerome Hagley
Printed Name
Executive Vice President
Title
Date
I, NotmhL M _ { � __^�. a Notary Public of the County
of 1)WQdQ& State of PCXQFQ_ hereby
certify that
appeared before me this day and under
Witness my hand and
Notan, Signature:
My Commission expires:
seal, t
acknowledge that this form was executed bt,Qi Iher.
day of Pi—:'brUO-�RA 20
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charlottenc.gov
Storm Water Services Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: 704:'336-6692
h= charlottenc^eov "develoymentcenter
Pa#e 2
Rev 09/2021

Additional Landowners
Name: Floyd Smith Office Park, LLC
Address: 5401 E. Independence Blvd
Charlotte, NC 28212
Telephone: [phone]
ax:
(Area Code) (Area Code)
Email Address: [e-mail]