NCC242905_FRO Submitted_20240923

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
1. Project name: Shopton Rd. W Townhomes
2. Address of land— disturbing activity: 11033 Shopton Rd. W
Charlotte, NC 28273
3. Approximate date land-disturbing activity will commence: 9 25 24
Month Day Year
4. Purpose of Development(Residential, Commercial,Industrial, etc.):Residential
5. Total acreage of land to be disturbed or uncovered:19.32
6. List total site acreage:20.097
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:CB Shopton Developers, LLC
Address:1905 Woodstock Rd. Suite 9250 Roswell, GA 30075
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: jeremy.wethington(adexeterdevco.com
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 39064 Page 855-860 Book 39064 page 852-854
Book 39064 Page 839-851 Book 39064page 835-838
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s)financially responsible for this land-disturbing activity (Note:If 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:CB Shopton Developers, LLC
Address:112 South Tryon St. Suite 1755 Charlotte, NC 28284
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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. (ram C`Cc ve/
Address: ((.2 Sp N 14, Y„,i S/r . ,,A /7Ss
C( .
(o 17 . /A(C- a n2Tr
Telephone: ?c2y-so7- 9vc)/ Fax:
(Area Code) (Area Code)
Email Address: , (&,I..7 -e a_xQ_irarc4{r1�,�j 4,t
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.)
Jeremy Wethington Director of Land Development
Prince Name Title
,ignature T PLL33CI
Date
(�I, I `��r p �/ ' v , a Notat y Public of the County
of u,,,t,e n . State of A 6 e 4l.. C�.� f,^k , hereby
certifi'that T.: -.e ot-i j U e'1"L.-i 4-e, personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this 12 day of Jertr..5�-- , 20-2'
Notary Signature: 1J ,�
My Commission expires. A., 1 12.2029
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tio ,�. ,,a charlottenc.gov
„iv'COtiN�,�044 Storm Water Services—Land Development
,f«tuakilk1i 600 East Fourth Street,Charlotte,North Carolina 28202-2844
Telephone:[phone]
http://charlottenc.eov/developmcntcenter
Rev.09,2021 Page 2