NCC216031_FRO Submitted_20211029

DocuSign Envelope ID: 32275429-EE93-4392-AOAF-1 B6COEA517AA
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: LOSO BUILDING 3
2. Address of land —disturbing activity: 3730 SOUTH BLVD (PID: 149-01-255)
CHARLOTTE, NC 28217
3. Approximate date land -disturbing activity will commence: 08
01
2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): COMMERCIAL
5. Approximate acreage of land to be disturbed or uncovered: 1.97
6. List total site acreage: 0.994
7. Landowners of Record (Use blank page to list additional owners):
Name: LOSO LAND #2 LLC
Address: 500 E MOREHEAD ST STE 200
CHARLOTTE, NC 28202
Telephone: [phone] Fax:
(Area Code) +
Email Address: [e-mail]
Signature:
Name: SCALEYBARK PARTNERS
Address: 310 S WEST ST STE 100
RALEIGH, NC 27603
Telephone: [phone] Fax:
(Area Code)
Email Address: [e-mail]
Signature:
(Area Code)
(Area Code)
'­D70CA3BE82F44AB...
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 34156
Page 757
Book 23460 page 612
Book Page
Book Page
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DocuSign Envelope ID: 32275429-EE93-4392-AOAF-1 B6COEA517AA
Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: LOSO LAND #2 LLC
Address: 500 E MOREHEAD ST STE 200
CHARLOTTE, NC 28202
Telephone: [phone] Fax:
(Area Code)
Email Address: matt(a beacondevelopment.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.)
Matt Lucarelli
Printed Name
Signature
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certify that
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Authorized Representative
Title
Date
a Notary Public of the County
State of L o r4l C-arp ( 1 Y e_� hereby
personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial se 1, this S�- day of 20 2-1
Notary Signature:
My Commission expires:
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Notary Public
Mecklenburg
County
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CIMLOTTI:.
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpermits.charmeck.org
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