NCC220267_FRO Submitted_20220114

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: Charlotte Rescue Mission Dorm
2. Address of land —disturbing activity: 907 West First Street Charlotte, North Carolina 28202
3. Approximate date land -disturbing activity will commence: October 15, 2021
Month Day
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Institutional
5. Approximate acreage of land to be disturbed or uncovered: 1.72
6. List total site acreage: 1.990
7. Landowners of Record (Use blank page to list additional owners):
Name: Charlotte Rescue Mission
Address: 907 West First Street Charlotte, North Carolina 28202
Telephone: [phone]
(Area Code)
Email Address: tony.marcianc
Signature:
Name:
Address:
Telephone:
(Area Code)
Email Address:
Signature:
mission.
Fax:
Fax:
(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 2121
Page 357
Book Page
Book Page
Book Page
Year
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Charlotte Rescue Mission - Tony Marciano
Address: 907 West First Street Charlotte, North Carolina 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
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 trust 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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Tony MarcianoZ?7- PresidentlCEO
Printed Name _ Title
Date
7 Lk-*� b- , a Notary Public of the County
�'�f ` y� ^ Of ,State of 'l ]� 0 ,hereby
certify that _� a 1 �6 - ''I��-'� Cam` personally
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 20�
Notary Signature:
My Commission expires:
Notary Public, North Carolina
My Commission Expires
August 26, 2022
ca�nn�.orrE.
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpen-nits.channeek.org
Page 2

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7. Lanclowwners of Record (Use blank page to list additional owners):
Name: Charlotte Rescue Mission
Address, 907 West First Street Charlotte, Nord) Carolina 28202
Telephone. [phone] Fax:
(Area {'_ode) (Area Code)
Entail Address: [e-mail]
Signature:
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