NCC232620_FRO Submitted_20230830

City of Charlotte & Mecklenburg 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: PIN 03724101, Mecklenburg County
2. Address of land—disturbing activity: 5201 Victoria Ave, Charlotte, NC 28269
3. Approximate date land-disturbing activity will commence: April 1, 2023
Month Day Year
4. Purpose of Development(Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 7.58 acres
6. List total site acreage: 27.59 Ac.
7. Landowners of Record(Use blank page to list additional owners):
Name: COUNTRYWOODS COMMUNITY LLC
Address: 8480 HONEYCUTT RD STE 200
RALEIGH NC 27615
Telephone: [phone] Fax: N/A
(Area Code) (Area Code)
Email Address: kenyon@a kdmdevelopment.com
Signature:
Name: Kenyon Burnham
Address: 8480 Honeycutt Road, Ste. 200
Raleigh, N.0 27615
Telephone: [phone] Fax: N/A
(Area Code) (Area Code)
Email Address: kenyon( )kdmdevelopment.com
Signature:
8. Indicate Book and Page where deed or instrument is filed(Use blank page to list additional deeds or
instruments) Book 12560 Page 227 Book Page
Book Page Book Page
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Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: COUNTRYWOODS COMMUNITY LLC
Address: 8480 HONEYCUTT RD STE 200
RALEIGH NC 27615
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: kenyon(a�kdmdevelopment.com
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Kenyon Burnham
Address:8480 Honeycutt Road, Ste. 200
Raleigh, N.0 27615
Telephone: [phone] Fax: N/A
(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.)
Kenyon Burnham Vice President - Managing Member
Printed Name Title
iN/z1
Signature I Date
1 I, _5 l�'1�, ,�€. .-kck \ , a Notary Public of the County
of 0 R , State of M oC-Vn C-- AS , hereby
certify that KA—Ay o1'1 0-1 V col In ct rs/1 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 ,4 f t-in , 20
Notary Signature: � �-
My Commission expires: A pc ,N am, a
•
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01ARLOTTEv = 4-24-2027
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ENGINEERING&PROPERTY
MANAGEMENT ,Q
Land Development Division ,` „ ,,,,, �4.
600 East Fourth Street, Charlotte,North Carolina 28202-2844 %,,,COUN ;,,0
Telephone: [phone] Fax: [phone]
http://landpermits.charmeck.org
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