NCC220238_FRO Submitted_20220112

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:
SOUTH OF HERITAGE POND DR., EAST OF SENATOR ROYALL DR. WEST OF LAGRANGER RD.
2. Address of land disturbing activity:
SOUTH OF HERITAGE POND DR., EAST OF SENATOR ROYALL DR. WEST OF LAGRANGER RD.
3. Approximate date land -disturbing activity will commence: January 01
2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): RESIDENTIAL
5. Approximate acreage of land to be disturbed or uncovered: 12.06 AC
6. List total site acreage: 17.94 AC
7. Landowners of Record (Use blank page to list additional owners):
Name: TEACHERS INSURANCE AND ANNUITY ASSOCIATION OF AMERICA
Address: 730 THIRD AVENUE NEW YORK NEW YORK 10017
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: kristina.lynn cr,nuveen.com
Signature: Kristina Lynn�age`202109".15091 23-a500'
Name:
Address:
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 10569 Page 840 Book Page
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:
Address:
CRESCENT COMMUNITIES, LLC
227 WEST TRADE ST. SUITE 1000
CHARLOTTE, NC 28202
Telephone: [phone] 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.)
I,
Of ((.l,
certify that
appeared before me this day and
J Gl' 1
Witness my hand and notar�yhl seal, this
�f r ,
Notary Signature._
My Commission expires:
�6�Niisiow////,i
Notary Public
1
Cabarrus _
County
My COMM. ExP- E
10-03-202.4 IT
R
a
oath i
11 MA M I ! / W1
Date
a Notary Public of the County
State of /V0441 [_C lif 0 % f %lam, hereby
personally
lwledge that thiskm was executed by him/her.
411 day of yie 20
•
(MARLOTTE.
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
hftp://landpermits.chartneck.org
Page 2