NCC240166_FRO Submitted_20240123

City of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
Financial Responsibility/Ownership Forni
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 Sedirnentation
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 tilled out accurately and complctcl`
Please Type or Print
PART A
1 . Project name: 3421 McKee Rd Townhomes
2. Address of land—disturbing activity : 3421 McKee Rd. Charlotte NC
3. Approximate date land-disturbing activity will commence: 01 /01/2024
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Total acreage of land to be disturbed or uncovered: 1 .90
6. List total site acreage: 2.33
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: Saraya Investment Holdings, LLC
Address: 12312 Copper Way, Suite 102, Charlotte NC 28277
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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 38394 Page 261 Book Page
Book Page Book Page
1 Pagc

Continue - Financial Responsibility/Ownership 1i orm
PART B
1 . Person(s) or finn(s) financially responsible for this land-disturbing activity (Note: tithe financially responsible
perron(s) or firm(s) has an ow-of.state address, a North Carolina agent must he designated in item 2 below):
Person or Firm: Saraya Investment Holdings, LLC
Address: 12312 Copper Way, Suite 102, Charlotte NC 28277
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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.)
\1.0035\ncx1 y4-4
Pruned Name Title
1( 11
( rjo3
Signature Date
.ec k , a Notary Public of the County
of Oft cAda nit)In , State of Nu'4 keN (a f- < v, , hereby
certify that e kASInoL1 P c\A-121
personally
appeared before me this day and under oath acknowledge that this firm it'us executed by him.her.
Witness my hand and notarial -cal, this 313 day of w - -(--- , 20 Z�
IIIIOIIIf
.ti otur7 r Signature: C4-4-0QPttao 4,Commtiss+ r� ��.�`��StA R. q�
Aly Commission expires: �y fleet 7,2024 ?�� 01'A � ,,'s
(a))
0 ,ov G
'BURG CBO V
is sinit‘I'Is%
charlottenc.gov
Storm Water Ser ices — Land De%elopment
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
http:/ charlottenc.gpv/develoomentcenter
Rev 09 2021 Page