NCC215710_FRO Submitted_20211014

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: Erwin Road Apartments
2. Address of land -disturbing activity:_ 12100 S. Tryon Street Charlotte, NC 28273 T
& 13925 ERWIN RD CHARLOTTE NC 28273
3. Approximate date land -disturbing activity will commence: October 15th 2021
Month Da
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial Multi -Family)
5. Approximate acreage of land to be disturbed or uncovered: 21.76
6. List total site acreage: 30.73
7. Landowners of Record (Use blank page to list additional owners):
Name: Mosby Steele Creek, LLC
Address:1921 Gallows Road, Suite 700, Vienna, VA 22182
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address:
Signature: �- -
Name- o���t�►-
ddress:
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 36571 page 451-453 Book Page
36571 458-464
Book Page Book Page
Page I

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firms} financially responsible For this land -disturbing activity:
Person or Firm: Mosby Steele Creek, LLC
Address:1921 Gallows Road Suite 700 Vienna VA 22182
Telephone: [phone]
(Area Code)
Email Address:
ax:
(Area Code)
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Finn: CT Cc
Address: 160 Mine La
u rt,
C 27615-6417
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 company or entity, if not an individual.)
Name
Title
1 V I 2 o2_1
te
(K a Notary Public of the County
of �►e_yw State of V 104 1 L-10 hereby
cert ify that 5 personally
appeared before me this day and :ender oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this �CUY day of t"C�l OCggg= 20 ' - l
Notary Signature. ��- aLi-��
My Commission expires: -r • 2"Z
�� 3�18A8CHARLOM
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• :�F ►/�►•�y. V ENGINEERING
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r+•4•ND~i�Q`'ti�''~ Land Development Division
IF% 1% 600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:[phone] Fax:[phone]
http://IandperTnits.chan-neck.org
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