NCC220659_FRO Submitted_20220209

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 Woodlawn TH Parcel F
1. Project where land -disturbing activity is to be undertaken:
2. Address of land —disturbing activity: 5000 Nations Crossing Rd 225 Charlotte NC 28217
3. Approximate date land -disturbing activity will commence: November 1 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential (Townhomes)
5. Approximate acreage of land to be disturbed or uncovered: 3.50 ac
6. List total site acreage: 2.92 ac
7. Landowners of Record (Use blank page to list additional owners):
Name: Accent Woodlawn Tomehomes Charlotte, LP
Address: 3715 Northside PY NW BLDG 400 SUITE 375
ATLANTA GA 30328
Telephone:,
(Area Code)
Email Address:
Signature:
Name:
Address:
Fax:
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 35411 Page 49
Book Page
Book Page
Book Page
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: Accent Woodlawn Townhomes Charlotte, LP
Address:3715 Northside Parkway NW Building 400 Suite 375
Atlanta, Georgia 30327
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
2. North Carolina agent, for the person or fine who is financially responsible:
Person or Firm: CT Corporation System
Address: 160 Mine Lake Court, Suite 200, Raleigh, NC 27615
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.)
Printed Name Title
9�'
ignaturej / , Date
I,
Of�
certify that
appeared before me this day and
Witness my hand and notark(l sec
Notary Signature:
My Commission
State of
oath i' c' knowledge that this form
a Notary Public of the County
hereby
personally
by him/her.
20
SHARON R CHANDLER
NOTACobb RY PUBLIC
State of Georgia
My CwvMssion EWm 12taBt2021
C�iLOTTE_
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://landpermits.channeck.org
Page 2