NCC243473_FRO Submitted_20241112

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-Stale,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
I. Project name: Carmel Chace
2. Address of land—disturbing activity: 11401 Turn Stone Ct., Charlotte, NC 28210
3. Approximate date land-disturbing activity will commence: October 01 2023
Month Day Year
4. Purpose of Development(Residential,Commercial, Industrial,etc.): Multi-Family Residential
5. Total acreage of land to be disturbed or uncovered: 4.99 acres
6. List total site acreage: 4.35 acres
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 I, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
Name: AVASA Carmel Chace,LLC
Address: 10100 Paris Cedar Dr., STE 166
Charlotte_NC 28210
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Name: Carmel Chace-HOA
Address: 1201 Stallings Road
Matthews, NC 28104
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: inforjkeycmi.com
8. Indicate Book and Page where deed or instrument is filed(Use blank page to list additional deeds or
instruments) Book 37739 page 278 Book 03939 Page 304
Book 37739 Page 276 Book 10696 Page 096
Page I

Name: Gatevday Homes II,LLC
Address: 6407 Idtewiln Rd, Unit 1113
Charlotte, NC 28212
Telephone: Fax:
(Area Cede) (Area Cade)
Email Address:
Name: Mecklenburg County
Address: 600 E.4iti Street ilth Floor
Charlotte, NC 26202
Telephone: Fax:
(AL Cade) (Area Code)
Email Address:

Continue - Financial Responsibility/Ownership Form
PART B
I. Person(s) or firm(s)financially responsible for this land-disturbing activity(Note:lithe financially responsible
persont')or,f'rrm(.s}has an out-vf=slateaddress.a North Carolina agent must be designated in item 2 blow):
( Person or Firm: 14446f1- GA-ii+f&L C44 t o u d--
Address: 10100 Park Cedar Dr., STE 166
Charlotte, NC 28210
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:
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 conpany or entity,if not an individual.)
f7k 5✓Se2 Sroc D/L/• �/A $-' �l-
Printed Name Title
S -30 `2 'z 3
Signa Date
Gt.m r tom. A . l )e .( / . a Notary Public of the Counfl,
of ///t1 `)e„n 1C71.SO� . State of `1lf'C Ltd r,�e i ram_ , hereby
certify that uS S e._)l S7 no-r r ( personally
appeared before me this day and under oath acknowledge that this form was executed byhim/her.
Witness my hand at :: arial seal, this .30 `// day f ` ') , 20.2 2
Notary Signatur'G�`."oir-ycc
MvCommission expires: '�J '4/ _DA P a`a0111111
It
onaA� ' 4/ #••
(CO)
Notery
�' PUblle
char!ottencegor� ''I��pf 'nt,u,ocA
a �'
Storm Water Services Land Development j1Nol I I1 rt G```��
600 East Fourth Street, Charlotte,North Carolina 28202-2 114 4
Telephone: 704•'336-6692
http: 'charlottenc.gov developmentcenter
Rev.O I202I I'