NCC215244_FRO Submitted_20211005

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 parry 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
Dunavant & Distribution
2. Address of land —disturbing activity: 2302 Dunavant St., Charlotte, NC, 28203
3. Approximate date land -disturbing activity will commence: April 1 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Multifamily
5. Approximate acreage of land to be disturbed or uncovered3.56 AC
6. List total site acreage: 2.85 AC
7. Landowners of Record (Use blank page to list additional owners):
Name: KA D&D Holdings LLC by Adam Gooch
Address: 601 13th Street NW, Suite 300, Washington, DC 20005
Telephone:[phone] Fax:
( rea od (Area Code)
Email Address: dou en akridge.com
Signature: 4cp�,n cam.$
Name: KA D&D Holdings LLC
Address:8255 Greensboro Drive, Suite 200, McLean, VA 22102
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: ptyrrell(cD_kettler.com
Signature: N/A
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 34498 Page
Book 34498 Page
383
401
Book 35114 Page
Book 34498 Page
410
392
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
KA D&D Holdings, LLC
Person or �b9
, Suite
Address:—,_� tte�28203
Telephone: [phone] Fax:
(Area Code)
Email Address: doutenLaIakridge.com
(Area Code)
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone: Fax:
(Area Code)
Email Address:
(Area Code)
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.)
Adam Gooch
Printed Name
40p,
Signature
Senior Vice President
Title
12/23/2020
Date
a Notary Public of the County
V �
of '1'\_&' 'b 5 '4'+ or- �V->til,b I State of hereby
certify that _ p�d-Nl/l- CrrCVo" personally
appeared before me this day and under oath acknowledge that this form wasexecutedby him/her.
Witness my hand and notarial seal this o� f day of � Y�-K/ 20,
Notary Signature:
My Commission expires: ) D'I �-' 1 L' - e2O -2I
•
CHARLOTTE
ENGINEERING&PROPEff Y
MANAGEMENT
KATHY E. MCDANIEL
UPt1BUC OISMICT OF COLUMBIA
*CMmMon Expires July 14, 2021
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://landpermits.charmeck.org
RIM
Page 2

Additional Deed and Book Page Numbers:
Book:
34498
Page:388
Book:
34498
Page:405
Book:
35114
Page:414
Book:
34498
Page:397