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NCC242660_FRO Submitted_20240829
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 Parkwood MXU 1. Project name: 2. Address of land—disturbing activity: 515 Parkwood Ave, Charlotte, NC 28206 3. Approximate date land-disturbing activity will commence: September 01 2023 Month Day Year 4. Purpose of Development(Residential, Commercial, Industrial, etc.): Mixed-Use 5. Total acreage of land to be disturbed or uncovered: 2.93 ac 6. List total site acreage: 2.93 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: 515 Parkwood Land, LLC Address: 436 E 36th Street Charlotte, NC 28205 Telephone: 980.220.0412 Fax: (Area Code) (Area Code) Email Address: anniespacecraft.city Name: CoHab Development, LLC d/bla Space Craft Address: Telephone: 980.220.0412 Fax: (Area Code) (Area Code) Email Address: annie@spacecraft.city 8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or instruments) Book 37254 425-428 Book 37254 Page 408-410 Book 37254 Page 415-418 Book Page Continue - Financial Responsibility/Ownership Form PART B I. Person(s) or firm(s) financially responsible for this land-disturbing activity(Note:If the financially responsible person(s)or frrm(s)has an out-of-state address, a North Carolina agent must be designated in item 2 below): Person or Finn:_515 Parkwood Land, LLC Address: —See Part A. Telephone: Fax: (Area Code) (Area Code) Email Address: 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: Northwest Registered Agent Service, Inc. Address:4030 Wake Forest Road, STE 349, Raleigh, NC 27609 Telephone: 980.220.0412 Fax: (Area Code) (Area Code) Email Address: annie©spacecraft.city 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.) - (t)v A tU'h 1'1 0 1'Lea -7")(6)\tli •V Printed Name Title '"); /4),(/ / i° [1- 2-2-- Signature ; Date I' I, /C -(r e CA , a Notary Public of the County , State of }leY WI (C (,(0(Gnek. , hereby certify that ,To h n U\it Lh personally appeared before me this day and under oath acknowlgdge that this form was executed by hint/her. Witness my hand and n /t al seal, this ) / �`` da of 6� �V0be , 20 cgc Notary Signature: � �� I C-1 My Commission expires: (1 I1 l � , c � r�rr�rNrrrruniuy,,��,, % ,,,.r.......... q WO sty �,• ate. ��, • MY COMMISSION t :EXPIRES• • ° ov #47,, US CO�0 .,, charlottenc. g .4„,„.i,u,arrr, Storm Water Services--Land Development 600 East Fourth Street,Charlotte,North Carolina 28202-2844