NCC243161_FRO Submitted_20241011

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land-disturbing activity covered by Chapter 17, Article 2 of the Charlotte City Code or
Section 6 of the Mecklenburg County Sedimentation and Erosion Control Ordinance prior to completing and filing this
form with the City of Charlotte Engineering and Property Management Department,Land Development Services Division
or Mecklenburg County Land Development Services. The financial responsibility 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 fmancially responsible party is out of State,a North Carolina agent must be assigned.
Please Type or Print
PART A
1. Project where land-disturbing activity is to be undertaken: Mallard Creek Townhomes
2. Address of land—disturbing activity: 9904 Mallard Creek Road Charlotte, NC 28262
3. Approximate date land-disturbing activity will commence: Fall 1014
Month Day Year
4. Purpose of Development(Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 8.42 ac
6. List total site acreage: 11.65 ac
7. Landowners of Record(Use blank page to list additional owners):
Name: John Harvey SR Alexander& Clyde M. Alexander(PID: 04715204)
Address: 9835 Pinewood Lane
Charlotte, NC 28269
Telephone: Fax:
(Area Code) (Area Code)
Email Address: ►,Qn
Signatur5)
Name: James A. Coleman & Edith C. Coleman IPID: 04 7 l 5205)
Address: 9904 Mallard Creek Road
Charlotte, NC 28262
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
ignature
Page I

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form.
No person shall initiate any land-disturbing activity covered by Chapter 17, Article 2 of the Charlotte City Code or
Section 6 of the Mecklenburg County Sedimentation and Erosion Control Ordinance prior to completing and filing this
form with the City of Charlotte Engineering and Property Management Department,Land Development Services Division
or Mecklenburg County Land Development Services. The financial responsibility 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.
Please Type or Print
PART A
1. Project where land-disturbing activity is to be undertaken: Mallard Creek Townhomes
2. Address of land—disturbing activity: 9904 Mallard Creek. Road Charlotte, NC 28262 .
3. Approximate date land-disturbing activity will commence: t;R<II_t.. „2024
Month Day Year
4. Purpose of Development(Residential, Commercial,industrial, etc.): Residential.
5. Approximate acreage of land to be disturbed or uncovered: 8.42 ae
6. List total site acreage: 11.65 ac
7. Landowners of Record (Use blank page to list additional owners):
Name: John Harvey SR. Alexander& Clyde M. Alexander (P11): 04715204)
Address: 9835 Pinewood Lane
Charlotte, NC 28269
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Ciignature:)
Narrie: James A. Coleman & Edith C. Coleman (ND: 04715205) (cIecea ecb
Address: 9904 Mallard Creek Road ,
Charlotte, NC 28262
Telephone: 8 23- 512'058. I Fax:
(Area Code) (Area Code)
Email Addr ss:batik, [e-mail] NI tYl0.em .emGi i •C.DIYi
i afore• j... .z. -r., X. 4:erfeyvt,ct.,"____
SERRy • Cdt-EMAKI LiN�A C. SmCTHERS
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GRZAMt-rE FALLS NC. Ta10 C
Page 1

Continue - Financial Responsibility/Ownership Form
Name: Simone I-I. 131akeh iP1D: 04715206)
Address: 19919 Church Street
Cornelius,NC 28031
Telephone: 9 0 UZ
(Area Code) (Area Code)
Email Address: P L At e t yeGc a i L. . Cc)/V.
6ignature:
Name: Kunal Dave (ND: 04715208)
Address: 11127 Fountain Grove Drive
Charlotte,NC 28262
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
8. Indicate Book and Page where deed or instrument is filed.(Use blank page to list additional deeds or
instruments) Book 35866 Page 763
02195 Page 234
08930 Page 689
21057 Page 96
Page 2

Continue - Financial Responsibility/Ownership Form
Name: Simone H. Blakely (PID: 04715206)
Address: 19919 Church Street
Cornelius,NC 28031
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name: Kunal Dave (PID: 04715208)
Address: 11127 Fountain Grove Drive
Charlotte, NC 28262
Telephone: 9w- -Tad-yJa( Fax:
(Area Code) (Area Code)
Email Address: JQX v Car'!
Signature: e6c-;;G:G6C1:t0g0=..
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 35866 Page 763
02195 Page 234
08930 Page 689
21057 Page 96
Page 2

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: Plat;nu,m Ok Aslnm core, 14-C.
Address: 210 ('POon Ave. LatcP(A)npd, N5 Mint
Telephone: '132-31pH-Pop Fax:
(Area Code) (Area Code)
Email Address:J)\G nUmApvc\owCS.c om
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Seo c Cc ot,t;ay
Address: (023 MN-NA d Rc6,6, Woxli,aw. Nc agI1
Telephone: 10 Li-a(05-H(goo Fax:
(Area Code) (Area Code)
Email Address: Secin c► c,2c\Ps-kr-n C.c nm
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.)
OtYxhn Gocdnn ►v\aY\e'q`t I`'lP * (
Printed •, Title
CA a31 Doal-I
Si , I e Date
1, &>,CON KP SParman , a Notary Public of the County
of OQC , State of N Qu) SJ.CSPN , hereby
certify that NOlxln 6rvcC\or) 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 23 day of SO 9t 2rn C , 20 am
Notary Signature: A¢e.aP'-npY-
My Commission expires: AU3USb, 15 aaai _
SARAH KESSERMAN •
NOTARY PUBLIC OF NEW JERSEY _ r
MY COMMISSION EXPIRES 8/1S/28 (CD)
COMMISSION 50213169
ENGINEERING&PROPERTY - - _ -
MANAGEMENT - - - Page I
Land Development Division
600 East Fourth Street,Charlotte,North Carolina 28202-2844