HomeMy WebLinkAboutNCC220271_FRO Submitted_20220113City of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
Financial. Responsibility/Ownership Form
No person shall initiate any land -disturbing activity on one or more acres as covered by Chapter 17 of the Charlotte
City Code of Ordinances before this form and an acceptable erosion and sedimentation control plan have been completed
and approved by the City of Charlotte. The financially responsible 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. All relevant
items on this fonn must be filled out accurately and completely
Please Type or Print
PART A
1. Project name: EdenBrook
2. Address of land —disturbing activity: 2515 Ellen Ave, Charlotte, NC 28208
3. Approximate date land -disturbing activity will commence: Jan 17, 2021
Month Day
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Total acreage of land to be disturbed or uncovered: 10.10
5. List total site acreage: 10.10
Year
7. Landowners of Record (attach accompanied page to list additional owners). If the landowner of record is not
the person(s) or firm(s) financially responsible as listed in Part B, item 1, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
Name:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Name:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book, 5 Q 60 Page G1 a q Book Page
Book3 0 Page ! a a Book Page
Page 1
Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity (Note: If the financially responsible
person(s) or firms) has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: Rebecca Development LLC
Address: 520 Eagleton Downs Dr. Suite D, NC 28134
Telephone: (704) 907 - 6767 Fax:
(Area Code) (Area Code)
Email Address: chksaleh@gmaii.com
2. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina agent:
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 c -jpny or entity, if not an individual.)
Charles Saleh Manager
Printed Name _' t Title
Signature Date
I, a Notary Public of the County
of ULM"�Mro State of UCK-Ra CUOD I M Ol hereby
certify that S SCA Jejhpersonally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this � day of ,�QYIUI,C�F'L! 20
Notary Signatu'e:
My Conrrnisson ex
. ANQUANETTE V WOLFE
Notary Pu41ic, North Carolina
Mecklenburg County
My Commission Expires
SM
char[vttenc.gov
Storm Water Services — Land Development
600 East Fowth Street, Charlotte, North Carolina 28202-2844
Telephone: 704/33 6-6692
httv://charlottenc.gov/develai)menteentef
Rev. 09/2021
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