NCC242731_FRO Submitted_20240904

City• of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
fit► pel.Ull .hall Inmate an% i,ttlk:•ai'tton.11. .I0i\it% on one Or more acres .ts co%tired t ( barter I- ut the l harlotle
( tit Code de e.f(1r(1+nan0e% hetore thl. form and an.I::or tahle erosion and sedimentation control plan haw been completed
a+,J appr4,%cJ h. the 1.it• of l harlotte I he tinani t:l h re.ponsihle pan) %%ill he on record as the part) to acceDI elt Notices
of \ iolaion or related dotumenh for and non-compliance of the (, +t' ,•' l harlotte ‘,otl I ro,•', and k'dinlentation
t Stun nnc If the ftnanciall responsible earth is out of State. forth l ari,Iuta agent mu.I tie a..,cned. \:i reie%.ul1
items nn !ill., (orm must he IiIIcd glut ,teettr;Iteh and compleleh
Pease pe or Print
PART A
Pi ujct I ttatua . /1 (44ds fOto 14 (12464,144.1 -
2. Address of Lu►d-Jisturbina 44.6%it. . 13411 Q,M*o I JA&L P1414.i44
3. \t►pt+ninlatc date kind-dihturh+ne 44-6.it. •.ill commence' T Y fr7 - . -- 20Z3
\L v►th I)a' 1 ear
4. Purpose of 1)e%elopment i Residential. 1. ommercial. Industrial. etc.I ttGsr t •4J
5. I utal at read e of land to he Ji.turhed or un:o%ered: 1041
n. I.1.1 total .it. asreaitc
Lando' ner. of Record (attach accompanied page to list additional ue.ner.I. I I•the lando ncr of record is not
the person(.( or tirm(s) tinanclall responsible as listed in Part R. item I. a separate letter ut consent signed
h\ the landumner of record or their authuriied agent is required:
\amc: 11111k1rt ..v1 P .+,wc
\ddre•s. 1341-1 6444 FANO-4 PL1A 1444041 — —
1 c lephone: f104* 664" 0174 _ Fax: - -- -
I \+..,( .,av t t aiea( ..t.
1 mad \dares. M1Lu- •.e77erill' 6101 — ---
\:one
1,I,trc��
I elephone: Fax:
t \peat,'Ste' t NI-eal ,xfet
(-mail Address.
K. Indicate Rook and Page %%here deed or instrument is tiled( (L se blank pave to list additional duds or
instruments, Book 1111( Page 40 Rook _Page
Hook Pace — Book Page -- -

C oniinue - Financial Respunsihiiii O%% nvr.hip Form
PART R
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„osier. t11r:t,ll,r. Ilartner. .illorne\ in ta:t. or other rer•on %silk :Iuthorrt to eNerutc lmlrumCnl• for the
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