NCC220939_FRO Submitted_20220308

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-disttrbuig activity is to be undertaken: Grounds for Chan
2. Address of land -disturbing activity: 3420 Park Rd, Charlotte, NC 28209
3. Approximate date land -disturbing activity will commence: November 1 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Multi -Family Residential
5. Approximate acreage of land to be disturbed or uncovered: 5.71 Acres
6. List total site acreage: 9.77 Acres
7. Landowners of Record (Use blank page to list additional owners):
Name: vrarae�sne� Ne `10rtM) -1`co i e.rl�S CA'WI",httrl / ► -! �J(1-10Y1 D( -fhe Oei*gj) ('ttrol, iiiis Inc,
Address: 3420 Park Rd Charlotte, NC 28209
Telephone:'-��� Fax:
(Area Code) (Area Code)
Email Address: til Vvicei ) Q" , 1
Signatur G l�• G _ 've P
Name:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 2375 Page 047 Book Page
Book Page Book Page
Page t

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or fin-n(s) financially responsible for this land -disturbing activity:
Person or Firm: Dreamkey Partners
Address: 4601 Charlotte Park Drive, Suite 350, Charlotte, NC 28217
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 Firm: Dreamkey Partners
Address: 14601 Charlotte Park Drive, Suite 350, Charlotte, NC 28217
Telephone: [phone]
ax:
(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 instnunents for the
financially responsible company or entity, if not an individual.)
aIle A-. ?Of-4r— pne__S ideI1
2 � .-
Signature D to
a Notary Public gl'the County
of --� State of &4a �(�rb l t lttx� hereby
certify that _:�4r_A�r personally
appecrr•ed beJare me this day and under oath acknowledge that this fornr was execrtted by hire/her.
Witness mY hct►zd and notal *ZU2
t, this J � *' dery of �tt /LPG 20 [
Notary Signanwe: J %t onln_�
ttily Commission expires:_ C
Notary Public, North CAralins
Mecklenburg County
• My Commission Expires
July 04, 2024
CHARLOTTE.
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax:[phone]
http://Iandpemiits.charmeck.org
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