NCC216626_FRO Submitted_20211130

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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: ConnelIX Creek Apartments
2. Address of land —disturbing activity: 4350 Connelly Circle, Charlotte, NC 28208
3. Approximate date land -disturbing activity will commence: Feb 01 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Multi -Family Residential
5. Approximate acreage of land to be disturbed or uncovered: 6.21 Acres
6. List total site acreage: 6.41 Acres
7. Landowners of Record (Use blank page to list additional owners):
Name: Connelly Circle, LLC
Address: 256 Victoria Ave
Charlotte, NC 28202
Telephone: [phone] Fax:
(Area Code)
Email Addres&-,,Vt—u-e*'[e-mail]
Signature:
Name: Monica Reid
Address: 9207 Duncanshire Ct
(Area Code)
Raleigh, NC 27613
Telephone: [phone] Fax:
Email Ad
k Red (Area Code)
Signature:
M 04t (&
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 32361 Page : y:01 Book 32361 Page
Book 32361 Page
Book 32362 Page
946
62
Book 32361 Page 889
Book 33531 Page 539 pass 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Dreamkey Partners
Address: 4601 Charlotte Park Drive
Suite 350, Charlotte, NC 28217
Telephone: [phone] Fax: [phone]
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Dreamkey Partners
Address: 4601 Charlotte Park Drive
Suite 350, Charlotte, NC 28217
Telephone: [phone] Fax: [phone]
(Area Code) (Area Code)
Email Address: [e-mail]
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.)
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signatu Date
�t" a NotaryPublic o the County
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Of
.State of Il! �1'f�- i h 4t _ hereby
certify that. lti �'!� _ _--personally
appeared before me this day and under oath acknowledge that this for was executed by him/her.
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Witness my hand and nota a a this day of 4
Notary Signature: - w�
My Commission expires A y Z
ASHTON N SLATE
NOTARY PUBLIC
Mecklenburg County
North Carolina
MY cormulon l;xPres March 18, 2022 �
CHARtOrM
ENMEM &MMOtrr
MANASMarr
Land Development Division
600 Bast Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpermits.chartneck.org
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