NCC243096_FRO Submitted_20241009

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 foiin must be filled out accurately and completely
Please Type or Print
PART A
1. Project name: Wells Fargo CIC
2. Address of land—disturbing activity: 1521 W WT Harris By
Charlotte, NC 28262
3. Approximate date land-disturbing activity will commence: 10 3 2024
Month Day Year
4. Purpose of Development(Residential, Commercial,Industrial, etc.): Commercial
5. Total acreage of land to be disturbed or uncovered: 2.10
6. List total site acreage: 2.10
7. Landowners of Record (attach accompanied page to list additional owners). If the landowner of record is not
the person(s) or firm(s)fmancially 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: Wells Fargo Bank, NA, successor in interest by merger to First Union National Bank of North Carolina
Address: 1521 W WT Harris By Charlotte, NC 28262
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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 7822 Page 949 Book Page
Book Page Book Page
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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: Wells Fargo Bank, N.A.
Address: Attn: Emily van Zyl
11625 Community House Rd Charlotte, NC 28277
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: Corporation Services Company
Address: 2626 Glenwood Ave Ste 550 Raleigh, NC 27608
Telephone:[phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
3. The above infoiniation 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.)
Wells Fargo Bank, N.A, by Emily van Zyl, Vice President
Printed Name J Title
7 r Gar% r� ����` l D
igna e Date
I, C_S , a Notary Public of the County
of NIeC�iL V1 ���i I , State of N.vY kr\ c Qs-Ai b >'�. , hereby
certify that .21r 1 1 1-1-AC \ t1-3.1\ � �L personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand nd notarial seal, th" k day o C—I—o 1/ , 20 ��
Notary Signature: �� �
My Commission expires: 1 ( I ( (0))
•
( JESI GOMEZ ZAVALA
I Notary Public-North Carolina
Mecklenburg County
My Commission Expires Oct 18, 2028
SM
charlottenc.gov
Storm Water Services—Land Development
600 East Fourth Street,Charlotte,North Carolina 28202-2844
Telephone:[phone]
http://charl o ttenc.2ov/dev elo pm entcenter
Rev.09/2021
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