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HomeMy WebLinkAboutNCC241594_FRO Submitted_20240611 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 PART A 1 . Project name: Keyton 2. Address of land—disturbing activity: 4711 Dixie River Road, Charlotte, NC 28273 3. Approximate date land-disturbing activity will commence: November 1 , 2022 Month Day Year 4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential - Multi-Family 5. Total acreage of land to be disturbed or uncovered: 150 ac 6. List total site acreage: 184. 12 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: Keyton, LLC Address: 5625 Fairview Road, Charlotte, NC 28209 Telephone: 704-343-4312 Fax: steveahoots childressklein.com (Area Code) Email Address: @ Name: Novant Health , Inc. Address: 2085 Frontis Plaza Blvd, Winston-Salem, NC 27103 Telephone: 704-316-4351 Fax: (Area Code) (Area Code) Email Address: mhstiene@novanthealth.org 8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or instruments) Book 38004 Page 234 Book Page Book 37827 Page 635 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: lf 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: Keyton, LLC Address: 5625 Fairview Road , Charlotte, NC 28209 Telephone: 704-343-4312 Fax: (Area Code) (Area Code) Email Address: steve.hoots@childressklein.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.) Sarah "Sally" Belk Gambrel) Manager Pri ted Name t� �� Title.6a64 isiejj ///1 /(01/ Signature Date F/atnaiJi /ZG1ir` , a Notary Public of the County of I iG- uU1 , State of /L)c?'v'iS - CO 'd1, eta- hereby y certify that sarcY. "�.�� �� Oak. Ga,nbri/ personally appeared before me this day any ) nd- . ., h acknowledge that this form was executed by him/her. Witness my hand and n s r. '. s,.l, t da of eknuct4n6 , 20 (94/ low Notary Signature: My Commission expires: S (a)) • HANNAH SMITH RANKIN h I' Notary Public, North Carolina � Mecklenburg County � My Commission Expires k � April 02, 2027 5M charlottenc.gov Storm Water Services — Land Development 600 East Fourth Street, Charlotte, North Carolina 28202-2844 Telephone: 704/336-6692 http://charlottenc.gov/deve lopmentcenter Rev. 09/2021 Page 2