Loading...
HomeMy WebLinkAboutNCC233266_FRO Submitted_20231101 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: Palisades Episcopal School Expansion 2. Address of land—disturbing activity: 13120 Grand Palisades Parkway,Charlotte, NC 28278 PID 21719176 3. Approximate date land-disturbing activity will commence: July 1, 2023 Month Day Year 4. Purpose of Development (Residential, Commercial, Industrial, etc.): School 5. Total acreage of land to be disturbed or uncovered: 2.22 acres 6. List total site acreage: 9.01 acres 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: Palisades Episcopal School Address: 13120 Grand Palisades Parkway, Charlotte, NC 28278 Telephone: 704-583-1825 Fax: (Area Code) (Area Code) Email Address: khughes@pescharlotte.org Name: Address: Telephone: Fax: (Arca Code) (Area Code) Email Address: 8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or instruments) Book 25689 Page 10 Book _ Page Book 49 Page 181 Book Page Page I 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(.) or firm(s)has an out-of-state address, a North Carolina agent must be designated in item 2 below): Person or Firm: Palisades Episcopal School Address: 13120 Grand Palisades Parkway, Charlotte, NC 28278 Telephone: 704-583-1825 Fax: (Area Code) (Area Code) Email Address: khughes@pescharlotte.org 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: Fax: (Area Code) (Area Code) Email Address: 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.) k7e).A.ya A-,,n V)e. }1-eo et ofc�GI/lb()) Printed Name �J Title Qignatu e Date H . to U o '- , a Notary Public of the County of z r‘.. , State of Pi !`fk 6K/dime._ , hereby certify that k eta' Kokes 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 1 -7 day of Al 47 , 20 2-3 Notary Signature: f" ._,� ���w{Dtr't��r`� yexpires: � oP h �` s M Commission /b—Z 4. o/ . • NOT �N `a o(CM = Ni & A O• 41C -sign Vki° IMEMEMMEO charlottenc.gov Storm Water Services—Land Development 600 East Fourth Street,Charlotte,North Carolina 28202-2844 Telephone: 704/3 3 6-6692 http://charlottenc.gov/developmentcen ter Rev.09/2021 Page 2