NCC241693_FRO Submitted_20240609

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land-disturbing activity covered by Chapter 17, Article 2 of the Charlotte City Code or
Section 6 of the Mecklenburg County Sedimentation and Erosion Control Ordinance prior to completing and filing this
form with the City of Charlotte Engineering and Property Management Department,Land Development Services Division
or Mecklenburg County Land Development Services. The financial responsibility 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.
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PART A
1. Project where land-disturbing activity is to be undertaken:
Myers Park Country Club (along Sharon Rd.)
2. Address of land—disturbing activity: 2415 Roswell Ave, Charlotte, NC, 28209
3. Approximate date land-disturbing activity will commence: July 8 2024
Month Day Year
4. Purpose of Development(Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 2.75 acres
6. List total site acreage: 168.79 acres
7. Landowners of Record(Use blank page to list additional owners):
Name: Myers Park Club INC
Address: 2415 Roswell Ave
Charlotte, NC 28209
Telephone: 704 ' 3 7k, - 074 J Fax: `?D 4 37 , - 5 l- 7 /
(Area Code) (Area Code)
Email Address: riL 26 GG C.a v1A_
Signature:
Name: ��yj1 -)d . yh )
Address: 2�41� J�Q� &// ,4ii , C G�.rrx-1d 7'7e 2e'a a
Telephone: 76 4. 3.7 to - D 7 4 / Fax: 76 4 - 3 74 - S-4 7 /
(Area C e) (Area Code)
Email Address: lSfxY,3 p Ave C'L G5I4.*
Signature:
8. Indicate Book and Page wh a ed r instrument is filed(Use blank page to list additional deeds or
instruments) Book 100 Page 001 Book 10015 Page 846
Book 10042 Page 487 Book 14347 Page 565
Book 17212 Page 690 Book _18870 Page 922 Page
Book 34597 Page 927

Continue - Financial Responsibility/Ownership Form
PART B
I. Person(s)or firm(s)financially responsible for this land-disturbing activity:
Person or Firm: Myers Park Club INC
Address: 2415 Roswell Ave,Charlotte, NC 28209
Telephone: Fax:
(Area Code) ���;�� � � (Area Code)
Email Address: ��acs , CA-
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: /24 Erc! �, c� + 014117 &'
Address: 9. 4-i 4 / y2 t.r 6// ,4t) GD�u�xl• iE AlC ze zo?
Telephone: 70 4 37 L ' / Fax: -0 4 • 3 76 • 6,7 /
(Area Code) (Area Code)
Email Address: d-411 L121 --� yyt. E.9te. pi-41—
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 r entity, if not an individual.)
Artgrg.-/eier
P 'nted N. Ti e
t
sign.re t Date
I, avv+�-°1 1lorbvti,:t- , a Notary Public of the County
of , State of A.t C. , hereby
cert that Qo��� {rnd.rei-4 ,Qv -i eL personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and no arial seal, this IA ,' day of •4-II ram( , 20 1q'
Notary Signature: %
My Commission expires: ( 7 R-
Khamla Sphabmixay
NOTARY PUBUC
(r1X.
Mecklenburg County,NC
My Commission Expires July 27,2025
CHARLOTTE.
ENGINEERING BA PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street,Charlotte,North Carolina 28202-2844
Telephone:[phone] Fax:[phone]
http://landpermits.charmeck.org
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