NCC230887_FRO Submitted_20230330

DocuSign Envelope ID: 1FE51E47-73A5-49BA-SFCO-ODBAD1DB1249
City of Charlotte & Mecklenhurg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity covered by Chapter 17, Article 2 of the Charlotte City Code or Section
6 of the Mecklenburg County Sedimentation and Erosion Control Ordinance prior to completing and filing this form with
the City of Charlotte Engineering and Property Management Department, Land Development Services Division or
Mecklenburg County Land Development Services. The financial responsibility 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.
Please Type or Print
PART A
1. Project where land -disturbing activity is to be undertaken: Northerly Townhomes (aka, "Atando Site"
Pro'ect No. ESDRMF-2021-00004
2. Address of land —disturbing activity: 2911 Statesville Rd., Lots 48 - 52„and 63 — 68 (Bldes 1009 & 1012)
3. Approximate date land -disturbing activity will commence: APHL 2023
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Townhome Construction
5. Approximate acreage of land to be disturbed or uncovered: 0.35 ac.
6. List total site acreage: 5.54 ac.
7. Landowners of Record (Use blank page to list additional owners):
Name (1) : Atando Avenue Partners LLC Beauxwri ht LLC
Address: 1900 W. Morehead St., Suite 201
Charlotte NC 28208
Telephone: [phone] p9 Fax: N/A
(Area Code) (Area Code)
Email Address: every. rozerskbeauxwri ht. com (Avery Rogers)
Signature: See Authorization Letter from Owner
Name (2):
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Fax:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 37346 Page 844 & 849 Book Page
Book Page Book Page
Page I

DocuSign Envelope ID: 1FE61E47-73A5-498A-8FCO-OD9AD1DB1249
Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: NVR. Inc. (dba Rvan Homes
Address: 13924 Professional Center Drive Suite 100
Huntersville, NC 28078
Telephone: CL04J 875-9887 Fax: [phone]
(Area Code) (Area Code)
Email Address:dkozuskakovrinc.cvnt (Ryan ILozusko)
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Finn: Corporation Service Compan
Address 262.6 Glenwood Avenue, Suite 550
_.. . ............
Telephone: [phone] Fax: N/A
(Area Code) (Area Code)
Email Address: N/A
I 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.)
P1*4.Ng ii gd by: Title
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of /de-
certify that
I
MA
State of
2/24/2023
Date
a Notary Public of the County
�D!/lv'�L.. hereby
personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and of riat seal, this a °� day of � 't 20
Notary Signature:
My Commission expires: 2 I 2'_-' a
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S:12023122306 - ATANDMOCSTRO ATANDO - NORTHERLY,DOCX
CfGNARG�i�'E.
MANAGEMENT
_ notary Public
Mecklenburg County
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Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://landpeTmits.channeck.org
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