NCC233819_FRO Submitted_20240103

I
Continue - Financial Responsibility/Ownership Form
PART B
I. 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 he designated in item 2 belo►t):
Person or Firm: G R Pell/ Cc ,4 --- eve-(4) cr j L- /)
Address: //2 S. , 7; .,,, Srt, S--c;k. /7 5r
G6,ci?fo ftd5 46 .a_eieY
Telephone: 70'f- S.? 7- Yam/ Fax:
(Area Code) ` (Area Code)
Email Address: i err�y�wc �n
2. If the Financially Responsible Party is not a resident of North Carolina, give namc 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.)
—17 is ti )Cit-/ r Pos.,a CLY-1
Printed Name Title
-113,A, rew,y,-----,
Signature Dat
i, T' 'i' 5 Tog , a Notary Public of the County
of MebKlenbej State of irorfh Cgrotirll , hereby
certifi,that Ti/ o'41 y rye' 1p r 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 31 I f+ day of eC t^'t 3 Gt--- . 20 3
7 (1
Notary Signature:My commission expires: 'f)(l l <3 �l
d 0 7
,,,1111„J •
,,,
V....1 ‘4,0 A z (CO)
.��i. '''
, '•:�, is
:,•S
•� charlottenc. ov
,, " v���, 600Storm Water Services—Land Development -
11I East Fourth Street,Charlotte,North Carolina 28202-2844
Telephone: [phone]
http:t'c harlottenc.uov/dove l opmentcenter
Rev.09/2021
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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: eed f Cr~ec lrt ?i ece rve
/os`�S" 3', /C2 r 3 L 11d5715- 3 2 3
2. Address of land—disturbing activity: 3 9C9c.9 rqD 4 lie, /slc �r', j5
3. Approximate date land-disturbing activity will commence: 0/ 03 2-02 V
Month Day / Year
4. Purpose of Development (Residential, Commercial,Industrial, etc.): j S -z
5, Total acreage of land to be disturbed or uncovered: 2- g• /3
b. List total site acreage: /IS: (Y8
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 I, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
Name: /� Crz��C 1vc � }vrs� P
Address: //Z 5, _171, 5< r` / 7Ss
life / //C 8' -.z/FS-
Telephone: 7o y _co -1— boo/ Fax:
(Area Code) (Area Code)
Email Address: tre�njro c:,JQ ;244 e •Ke}Kr de vc- , Cc�•✓l
Name:
Address:
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 S 'S /g" Page S03 `30 7 Book Page
Book Page Book Page
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