NCC220891_FRO Submitted_20220224

City 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 form must be filled out accurately and completely
Please Type or Print
PART A
1. Project name: HANOVER SOUTH END
2. Address of land —disturbing activity: 2301 S Tryon
Approximate date land -disturbing activity will commence: DEC 12
2021
Month Da Year
4. Purpose of Development (Residential, Commercial, Industrial, etc, COMNIERCTL
5, Total acreage of land to be disturbed or uncovered: 4 . 60
6. List total site acreage:
M
Landowners of Record (attach accompanied page to list additional owners). If the landowner of record is not
the person(s) or fin-m(s) financially responsible as listed in Pant B, item 1, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
Name: HANIMf JV SOUTH END NC LLC
Address: 1780 S. POST OAK LN.
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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 36192 Page 25
Book 36192 Page.
605
Book_ 3419I Page 346
Book 3 4191 page 377
rngr- I

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity (Note: ff the financially responsible
person(v) or firrn(s) has an out -of --state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: GREG BANKS - Hanover RS East Construction LLC.
Address: 817 E MOREHEAD
CHARLOTTE, NC 28202
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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: GREG BANKS - Hanover RS East Construction LLC.
Address: 817 E MOREHEAD
CHARLOTTE, NC 28202
Telephone:
8055580283
Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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 Ns _ Title
Date
a Notary Public of the County
rjaf hereby
alzaily
appeared before me this day and under oath acknowledge that this form was executed by hint/her,
Witness my hand and notarial seal, this L5 day of Z-81Z20Z I
Notary Signature.,
My Commission expires
charlottenc.gov
Storm Water Services — Land Development
600 East Fourth Sheet, Charlotte, North Carolina 28202-2844
Telephone: [phone]
httn://charlottenc.aov/develonmentcenter
iiw1rr,
Rev. 09/2021
Page 2