NCC220130_FRO Submitted_20220111

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: Westrow Phase 1 Infrastructure
2. Address of land —disturbing activity: Dixie River Road, Charlotte, NC
3. Approximate date land -disturbing activity will commence: December 22 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Mixed -Use
5. Approximate acreage of land to be disturbed or uncovered: 86.0 Acres
6. List total site acreage: 67.86 Acres
7. Landowners of Record (Use blank page to list additional owners):
Name: Crescent River District LLC
Address: 2601 South Tryon Street, Suite 800, Charlotte, NC 28202
Telephone: [phone] Fax:
Email
Signature:
Name:
Address:
mmunities.com
Telephone: Fax:
(Area Code)
Email Address:
Signature:
(Area Code)
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 32152 Page
Book 32809 Page
282
788
Book Page
Book Page
Page I

Continue - Financial. Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Crescent River District, LLC (Chase Ke
Address: 601 South Tryon Street, Suite 800, Charlotte,
28202
Telephone:_(980) 321-6161 Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
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.)
Chase Berle
RRIM OWN M'- 'I M
1. 21 21
Date
I izzam ::z lCLA Z. , a Notary Public of the County
oState of tJc271*t C.4tza ­ no, . hereby
certify that - C4 a S e r12 i' personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notariqj,!#ad, this Z 1 day of .1�-'cPr+ 6e�-?- 20 Z I
Notary Signature:
My Commission expfr; ! Z -
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Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpermits.charmeck.org
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