NCC220867_FRO Submitted_20220223

Consultant: OAK Engineering
Luke Bugeske, PE
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Luke@Oak. Engineering
SEDIMENTATION POLLUTION CONTROL ACT 704.559.9456
EXPRESS PERMITTING OPTION
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.
1. Project Name.
2.
3.
4.
5.
Project Hub
Location of land -disturbing activity: County Mecklenburg City or Township
Highway/Street Wilkinson Blvd Latitude 35.242127* Longitude_
Approximate date land -disturbing activity will commence: 3/1/2022
Charlotte
-80.955910*
Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 60.0
6. Amount of fee enclosed: $ 8,000 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900).
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 CHRIS URQUHART E-mail Address [e-mail]
Telephone [phone]
Cell # 704.236.2440 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CITY OF CHARLOTTE (C/O REAL ESTATE) 704.236.2440
Name Telephone Fax Number
600 E 4th STREET
Current Mailing Address Current Street Address
CHARLOTTE NC 28202
City
State Zip City
State
Zip
10. Deed Book No. 07145 Page No. 360 Provide a copy of the most current deed.
Part B.
1. 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.
CH-M HUB CLT, LLC
(ATTENTION: MATTCOCHRANE) [e-mail]
Name E-mail Address
3889 MAPLE AVE, SUITE 200
Current Mailing Address
DALLAS TX 75219
City State Zip
Telephone: [phone]
Current Street Address
City
State
Zip

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:
CT Corporation Systems [e-mail]
Name
160 Mine Lake Ct, Ste 200
Current Mailing Address
Raleigh, NC 27615-6417
City
E-mail Address
Current Street Address
State Zip City
Telephone [phone]
Fax Number
State Zip
(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:
Name of Registered Agent
Current Mailing Address
City
State
E-mail Address
Current Street Address
Zip City State Zip
Telephone Fax Number
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
correct d information should there be any change in the in rrqation provided herein.
V 1.�
Type or print name Title or Authority
09 /�
SigndtLfrcV Date
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Wl�Itaf"'s `
I, , a Notary Public of the County ofj-
State of North Carolina, hereby certify that (�)"4 Cgj1rM'f appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand andq notarial seal, this
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