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HomeMy WebLinkAboutNCC233707_FRO Submitted_20231220 City of ar otte Soil Erosion Sedimentation Control r i a c e 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 Clear Creek Crossings 1. Project name: 2. Address of land—disturbing activity: 12901 & 12809 Albemarle Road, Charlotte, NC 28227 3. Approximate date land-disturbing activity will commence: 11 01 2022 Month Day Year 4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial 5. Total acreage of land to be disturbed or uncovered: 17.50 ACRES (15 ACRES PREVIOUSLY PERMITTED PER EGP 6. List total site acreage: 11.24 (LDC-2022-00133)) 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: Clear Creek Crosssings, LLC Address: 630 S Maitland Ave., STE 100 Maitland, FL 32751 Telephone: 407-628-0077 Fax: (Area Code) (Area Code) Email Address: rstahl@equinox-development.com Name: Jerry N Helms Family Trust Address: 11901 Albemarle Road Charlotte, N.C. 28227 Telephone: Fax: (Area 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 37259 Page 639 Book 30741 Page 690 Book 27950 page 406 Book 37259 Page 650 Page 1 Confgnue Viill a>ia1 Responsibility/Ownership Form PART B 1. Person(s) or firm(s)financially responsible for this land-disturbing activity(Note:If the financially responsible person(s)or firm(s)has an out-of-state address, a North Carolina agent must be designated in item 2 below): Person or Firm: Clear Creek Crosssings, LLC Address: 630 S Maitland Ave.. STE 100 Maitland, FL 32751 Telephone:407-628-0077 Fax: (Area Code) (Area Code) Email Address: rstahl ct,equinox-development.com 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:Ryan P. Stahl Address:12809 Albemarle Road Charlotte, NC 28215 Telephone: 407-628-0077 Fax: (Area Code) (Area Code) Email Address: rstahlRequinox-development.com 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.) Ryan P. Stahl Manager Printed Name Title a�afl/a3 Signature Date I �-f !Sigh kS , a Notary Public of the County of Orange ,State of Florida , hereby certify that Ryan P. Stahl personally appeared before me this day and under oath acknowledge that this form was executed by him/her. Witness my hand an, nstarial seal, this c7.0441 day of T-d2rvaini 20, 3 Notary Signature: ! VV V My Commission expires: s I a. / a 3 • rooitYP p KRISTIN BANKS Commission#GG 339771 Expires May 29,2023 (CO) fFOF 0.01' Bonded Thru Budget Notary S,rvIee6 gMEMIMIMMO sH charlottenc.gov Storm Water Services—Land Development 600 East Fourth Street,Charlotte,North Carolina 28202-2844 Telephone:704/336-6692 http://charlottenc.gov/develo pmentcenter Page 2 Rev.09/2021