NCC240968_FRO Submitted_20240403

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: Woodspring Suites- Northlake
2. Address of land—disturbing activity: Statesville Road, Charlotte, NC 28269
3. Approximate date land-disturbing activity will commence: October 1, 2023
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial
5. Total acreage of land to be disturbed or uncovered: 2.34 ac
6. List total site acreage: 5.762 ac
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: Panos/Smith Hotel Group-Reames Road LLC
Address: 245 W Garrison Blvd, Suite G
Gastonia, NC 28052
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
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 10710 Page 261 Book Page
Book Page Book Page
Page 1

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: Concord WP COL Charlotte-Northlake LLC
Address: 11410 Common Oaks Road
Raleigh,NC 27614
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: chris.haleaconcordhotels.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:
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.)
L&\*.t. c)Ak.t v►cat PaSi
Printed Name Title
LOU,
Signature Date
I, \±k(,AQ,d _ �� f k,Q� , a Notary Public of the County
of AsAstAk , State of LigL' , hereby
certify that kAZILD, . 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 , CY.1 ,,, day of A , 20 2 1
Notary Signature: .64A. �
My Commission expires: I21/i /2.02g
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charlottenc.gov z ,%"G •
9.
Storm Water Services—Land Development 4,••y6�g•
600 East Fourth Street,Charlotte,North Carolina 28202-2844 loot C0U `SSA%
Telephone: [phone]
http://charlottenc.gov/developmentcenter
Rev.09/2021 Page 2

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete,scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with$120 check if paying by check)
at:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N. Salisbury Street,6th Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Per NC General Statute 143-215.6B(i), any person who knowingly makes any false statement, representation, or
certification in any application, record,report,plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article. . .shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
O I am the person responsible for the construction activities of this project,for satisfying the requirements of this
permit,and for any civil or criminal penalties incurred due to violations of this permit.
❑✓ The information submitted in this NOI is,to the best of my knowledge and belief,true, accurate,and complete
based on my inquiry of the person or persons who manage the system,or those persons directly responsible for
gathering the information.
❑✓ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
O If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
0 I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s)and is enforceable in the same manner as an
individual permit.
Project Name (must match Ala): Woodspring Suites - Northlake
Specific Lot Numbers(must match Alb):
Permittee(must match B1): Concord WP COL - Northlake LLC
Legally Responsible Person (must match B2& 83): Julie Richter
Title of Legally Responsible Person (must match B3b): Vice President
Print Name&Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: 919-455-2900
12/29/24
Signatu of Le L Legally Responsible Person or Authorized Individual Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president,secretary, treasurer,or vice president,or a manager that is authorized in accordance with Part IV,Section B,
Item(6)of the NCG010000 permit.