NCC242882_FRO Submitted_20240918

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 Please Type or Print
1. Project name: Rea Farms Sports Medicine Center
2. Address of land-disturbing activity: 11415 Golf Links Dr.
Charlotte, NC 28277
3. Approximate date land-disturbing activity will commence: Sep. 1
2024
Month
4. Purpose of Development(Residential,Commercial,Industrial,etc.):Mixed Use Day Year
5. Total acreage of land to be disturbed or uncovered: 6.1
6. List total site acreage: 5.59
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:Rea Park Lane 1031 LLC
Address: PC Box 471276 Charlotte, NC 28247
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: Robc taylor-capitai.corn
Name:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
8. Indicate Book and Page where deed or instrument is filed(Use blank page to list additional deeds or
instruments) Book 30659 Page 51 Book Page
g
Book Page Book Page
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Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s)or finn(s)financially responsible for this land-disturbing activity(Note:If the financially responsible
person(s)or firm(.$)has an out-of-state address,a North Carolina agent must be designated in item 2 below):
Person or Firm:Rea Park Lane 1031 LLC
Address: PO Box 471276 Charlotte, NC 28247
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: Rob@a taylor-capital.corrl
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.)
eo>,ec yl� Aeg3„1„.
Printed Name Title
W4(—?(?(/1
Signature S"7a3/a y
Date
/ r r (A( t J L F�%Y\y'1 Q li
� � ,� a Notary Public of the County
of Mt-CO' , State of Noy CUT\`l rlcl, , hereby
certi)5;that geKRY 1. (
personally
appeared before me this day and under oat acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this Z2 r`‘ day of 1•1\0.1 , 20 2i
Notary Signature:
My Commission expires: D c.-em\D.€-'V 'C((1))
•
TRACEY L.PANNELL
Notary Public—State of North Carolina
County of Mecklenburg
1111limis! My Commission Expires December 15,2027
charlottencegov
Storm Water Services—Land Development
600 East Fourth Street,Charlotte,North Carolina 28202-2844
Telephone: [phone]
Rev.09/2o2i http://charlottenc.govidevelonmentcefater
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