NCC216577_FRO Submitted_20211124

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 fling this
form with the City of Charlotte Engineering acid 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
L Project where land -disturbing activity is to be undertaken: 110 East
ParcelID's: 12101504A 12101503. 12101505
2. Address of land —disturbing activity: 1816 South Blvd. Current Address 110 East Blvd. Future Bld
Address 1820 South Blvd and 1812 South Blvd Charlotte NC 28203
3. Approximate date land -disturbing activity will commence: .Tune 1 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 1.59
6. List total site acreage: 2.00
7. Landowners of Record (Use blank page to list additional owners):
Name: EAST WEST STATION RETAIL,_ LP c/o Shorenstein Realty Services _ Attn: Steven P. Shanks
Address: 235 Mont ome Street -- 166 Floor —San Francisco CA 94104
Telephone: [phone] Fax: NIA
(Area Code) (Area Code)
Email Add
Signature:
Name:
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Fax:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 33995 Page 859 Book.
Book Page
IBM
Page
Page
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Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land. -disturbing activity:
Person or Firm: EAST WEST STATION RETAIL LP - Attn: Steven P. Shanks
Address: 235 Mont ome Street 16'h Floor
San Francisco. CA 94104
Telephone: _ [phone]
Fax: NIA
(Area Code) (Area Code)
Email Address: sshanks Shorenstein.com
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Chris N. Grenier, SVP of Development - Stiles Corp.
Address: 300 W. Summit Ave. — Suite 230 Charlotte NC 28203
Telephone: [phone] Fax: N/A
(Area Code) (Area Code)
Email Address: chris. =renier stiles.com
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.)
Steven P Shanks
Printed Name_, �,
Signature
Vice President
Title
q5j�'l
Date
I, li - '9 a a Notary Public of the County
of . State of d 1,'Aer7114 hereby
certify that P"0 YC�, 00
,, &4ArAC_f personally
appeared before me this day and under oath acknowledge that this form was executed b} rir /her.
Witness my hand and notarial seal, this OS? day of, ._ %1
Notary Signature: �_121,
My Commission expires: 69Z I 2a Z Z
*
CAISTIAN DEL TARO-DELGADO
r CY PUaLIIC*CA IFO
[i} - • j. NOTARY PU$L!C•CALlFORFflA �
ALAMEDA COUNTY -,
r My Commission Expires
AUGUST 13, 2022
ENGINEERING & PROPERLY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpennits.charrneck.org
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