NCC220825_FRO Submitted_20220218

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West Blvd FRO.pdf
DocVerify ID: FCEDC31 B-2980-4CFC-A265-AE203CEB73FA
Created: February 23, 2021 08:40:25 -8:00
Pages: 2
Remote Notary: Yes / State: NC
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ESignature Summary
E-Signature 1: CHase Kerley (CK)
February 23, 2021 08:50:04 -8:00 [B6434990D7B6] [66.129.118.228]
[e-mail] (Principal) (Personally Known)
E-Signature Notary: Teri A. Edwards (TAE)
February 23, 2021 08:50:04 -8:00 [59FECOE5DF26] [98.121.237.143]
[e-mail]
I, Teri A. Edwards, did witness the participants named above electronically
sign this document.
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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/or fax information
unavailable, place N/A in the blank.)
Part A.
Project Name West Blvd
2. Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street NC160 Latitude 35.19097 Longitude-80.96469
3. Approximate date land -disturbing activity will commence: 08/01/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Transportation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 36.81
6. Amount of fee enclosed: $ 2,405 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dan Melvin E-mail Address dmelvina-landdesign.com
Telephone [phone] Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Crescent River District 980-321-6000
Name Telephone Fax Number
227 W Trade St. #1000
Current Mailing Address Current Street Address
Charlotte NC 28202
City State Zip City State Zip
10. Deed Book No. 35496
Part B.
Page No.
•..
Provide a copy of the most current deed.
Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Crescent Communities ckerley(cDcrescentcomm unities. corn
Name E-mail Address
227 W. Trade St. #1000 227 W. Trade St. #1000
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28202
City State Zip City State Zip
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Telephone [phone] Fax Number N/A
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent:
N/A
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
N/A
Name of Registered Agent
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Chase Kerley
Type or print name
C�fase Kerley
Signature
Teri A. Edwards
Managing Director
Title or Authority
02/23/2021
Date
a Notary Public of the County of Mecklenburg
State of North Carolina, hereby certify that Chase Kerley appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this 23rdclay of
Teri A. Edwards
Electronic Notary Public - North Carolina
Mecklenburg County
loy Commission Expires May 07, 2025
February
Notary 'A,�q f�
My commission expires
20 21
May 7, 2025
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