NCC242711_FRO Submitted_20240909

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name Matheson Ave Streetscape
2. Location of land-disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street Matheson Ave Latitude 35.245543 Longitude -80.812978
September 2024
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Transportation
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7 Ac
6. Amount of fee enclosed: $ 520.00 . The application fee of$65.00 per acre (rounded
up to the next acre)is assessed without a ceiling amount (Example: a 9-acre application fee is$585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Adam Jarman [e-mail]
Name E-mail Address
Telephone [phone] Cell# - Fax# -
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Charlotte 704-336-2291 704-336-4554
Name Telephone Fax Number
600 East fourth St 600 East fourth St
Current Mailing Address Current Street Address
Charlotte NC 28202-2844 Charlotte NC 28202-2844
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
See attached sheet. Right of Way acquisition is currently in progress.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
City of Charlotte [e-mail]
Name E-mail Address
600 East fourth St 600 East fourth St
Current Mailing Address Current Street Address
Charlotte NC 28202-2844 Charlotte NC 28202-2844
City State Zip City State Zip
Telephone [phone] Fax Number 704-336-4554

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath is form must be signed by the Financially Responsible Person if an individual
or his attorney-i act,'or if not an individual, by an officer, director, partner, or registered agent with
the authority t ec/ate instruments for the Financially Responsible Person). I agree to provide
corre ted inf r ion should there be any change in th- information provided herein.
ype or pr e Title or A uthorit
' natu Date
I, , a Notary Public of the County of
State of North Carolina, hereby certify that t appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of , 20 C-
rm
:' Notary
Seal NOTARY
=0 PUBLIC OE My commission expires