NCC240318_FRO Submitted_20240209

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: River District Westrow Residential
2. Address of land—disturbing activity: Dixie River Rd, Charlotte NC
3. Approximate date land-disturbing activity will commence: February 1 2024
Month Day Year
4. Purpose of Development(Residential, Commercial, Industrial, etc.): Residential
5. Total acreage of land to be disturbed or uncovered: 16.0 acres
6. List total site acreage: 67.3 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: Crescent River District, LLC
Address: 601 South Tryon Street, Suite 800, Charlotte, NC 28202
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 32152 Page 282 Book 38187 Page 794
Book 35876 Page 075 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(s)or firm(s)has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: Crescent River District, LLC
Address: 601 South Tryon Street, Suite 800, Charlotte, NC 28202
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 m e signed by the financially responsible person if an individual or by an
officer, director, partner, atto ey n-fact, or other person with authority to execute instruments for the
financial! o pany or entity, if not an individual.)
Raine .Ficken Senior Managing Director
Printed Name Title
i/ 3/zaz4-
Signature ^ A ���f /J�� Date
4 m � i/ - �G !�L.�/�'W,45 [ ,�aa Notaryot Public o the County
of 1//G �..CY A3 State of /Oil I, e4WOL Al , hereby
certify that //Q//) /- / en personally
appeared before me this day and under oath acckkn wledge that this form was executed b i /her. �[/
Witness my hand and notaria seal,.this 47.— day of AV 2Q:�1 7
Notary Signature: ., •
My Commission expires: /i/L�.(� f t
(�/
`�,(CO) TERI A. EDWARDS
^� ;, Notary Public. North Carolina
�q--; Mecklenburg County
`s`:i'if t: My Commission Expires
' May 07.2025
charlottenc.gov
Storm Water Services Land Development
600 East Fourth Street,Charlotte,North Carolina 28202-2844
Telephone:[phone]
http. charlottenc.govrdevelopmentcenter
Rev 09t2021 Page 2