NCC232428_FRO Submitted_20230811

•coc, Mecklenburg County Soil Erosion and
Mai Sedimentation Control Ordinance
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RT Financial Responsibility/Ownership Form
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No person shall initiate any land-disturbing activity covered by Section 6 of the Mecklenburg
County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to
completing and filing this form with Mecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance with the above Ordinances. If the
fmancially 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: Atrium LKN Construction
2. Address of land-disturbing activity: 18213 Statesville Road
Cornelius, North Carolina
3. Approximate date land-disturbing activity will commence: JULY 1 2023
Month Day Year
4. Purpose of development (Residential, Commercial, Industrial, etc.): COMMERCIAL
5. Approximate acreage of land to be disturbed or uncovered: 28.50 AC
6. Total site acreage: 98 AC
7. Landowners of record(use blank pages to list additional owners as necessary):
Owner#1 Name: The Charlotte-Mecklenburg Hospital Authority
Address: 9401 Arrowpoint Blvd Charlotte, NC 28273
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner#2 Name:
Address:
Telephone: Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed(use blank pages to list
additional deeds or instruments as necessary):
Book 34138 Page 27 Book Page
Book Page Book Page
(continue on back or separate pages as necessary)
Form Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: The Charlotte-Mecklenburg Hospital Authority
Address: 9401 ARROWPOINT BLVD CHARLOTTE, NC 28273
Telephone: [phone] Fax:
Email Address: Amanda.Mewborn©atriumhealth.org
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: The Charlotte-Mecklenburg Hospital Authority
Address: 9401 ARROWPOINT BLVD CHARLOTTE, NC 28273
Telephone: [phone] Fax:
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.)
Aartt lV1 ewI0vvi i p1 ( II 11 i I/1 PCS 1 p C&&S- a Cy
Pr' ted Name Title
VhOP� .?A_ IoZ
Signature Data
I, At;lynh N 3 toCKVnC mC\ , a Notary Public of the
County of Mcc,cumbVY9 , State of tAntk r, C. 003VA(, , hereby
certify that 11\roonC\G ‘4171-oY1 personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand an notarial seal this 2-1tA day of )(\mjatx , 2023 .
Notary Signature: M ''D
My Commission expires: P\ 2O L :•`a: • - ,;�
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Mecklenburg County Land Use and Environmental Services Agency 3 pu B L1 C =L'
2145 Suttle Ave. : � ,`•. ,•
Charlotte,NC 28208-5237 :.��burg CoA
Phone[phone] „•,