NCC221552_FRO Submitted_20220421

I Q� 17 '14, 7 0 t .1 1 -� I - I i :" ;'L1 1- TTMI= Op" on rf I "M
No person shall initiate any land -disturbing activity covered by Chaff 17, Article 2 of the Charlotte City Code or
Section 6 of the Mecklenbrag County Suffinitaffori and Erosion Control Ordhi moe prior to completing and filing this
farm with the City of Charlotte Eno ring and Property Mariagie Trent Dgwt ner$, Land Developrnerrt Services Division
or Meddenbrag County Land Development Services. The fir><ur W responsibility party will be on record as the peaty to
accept arty Notices of Violation or related documents for any con compliance of the City of Charlotte Soil Erosion and
Sedimartabon Ordinance. If the firwicially responsible party is out of State, a North Carolina agerrt n ist be assigned.
PleeseTypearl('tit
PART A
1. Project where lanrd_dishurbing activity is to be undertaken.Riverbend Village Parcel G
2. Address of lam-dishabing activity: 3842 Corning Place Charlotte, NC 28216
3. Apprnxin-Aite rime land-distabing activity will eommeroe: June 1 2020
Morth Day Year
4. Puupose of Developer nt (Residential, Conjn rcial, inmstrial, etc.): commercial
5. Approxkmte aueage of land to be dWurbed oru rcovered: 3.30
6. List total site arm: 5.099
7. Lwxbvmxs of Record (Use blank page to list additional owrims):
Name: MT Island Promenade LLC
Addiess;1401 Sunset Drive Suite B Greensboro, NC 27408
TeleptrOne: 336-508-2801 Fax:
(ArEa CoM (Area Co&)
Ernail Address; sam@simpsonere,com
Sigriahrre
Name:
Address:
Telephone: Fax:
(Area Code) (Area Code)
Emil Address: _
V : 4 I
8. Indicate Book and Page where deed or irrstrwne t is filed (Use blank page to list additional deeds or
instrm) Book29667 pape 179
Book Page
Book Page

k'_1 1 1 1 I .1 1 : 1 I l f, L 1jiko_..1._1 1__
PAW B
1. Person(s) or firm(s) financially responsible for this land-&sturbirlg activity:
PeisonorFhm MT Island Promenade LLC
Address: 1401 Sunset Drive Suite B Greensboro, NC 27408
Telephone: [phone] Fax:
(Area Code) (Area Code)
Er ail Address: sam(c�simpsoncre.com
2. North Carolina agent, for the person or firm who is financially responsible:
Telephone:
(Area Code)
Er nail Address:
Fax:
(Arm Code)
3. The above infonymuon is hue and cornet to the best of my lmowlo* and belief and was provided by me
while under oath. Mrs form nxist be signed by the financially responsible person if an individual or by an
officer, director, partner, attorney -in -fact, or other person with audixity to execute irntarrerds for the
financially responsible cornpany or entity, if not an individual.)
No /L A
Title
signatrQe
515-
z
Date
1, • Dom/ D 5 E o -- , a Notary Public of the County
Of au l (�`r rc� �, ur. `t � , state of A) C - herd'
certify that plow lly
appeared before the Bus day and under oath adazWedge ttrat this fonn was ewaued byhHnher.
Witness myhand arxl notarial seal y of a - - , 20 2 d
Notary Signaituae: —�
MyCImmssionexpkes:_ O51'J?7 o -a
f
CHARIATTF_
ENGINEERING & PROPERTY
p �Rk,�® MANAGEMENT
y/.Yl' "y4 lad lard Development Division
�t l i1 to
lit ' 600 East Fotuth Street, Charlofte, North Carolina 28202-2844
Telephom: 7O 336-6692 Fax: 7OV336-6586
http:/Aan*wiAfs-dwn leck.org
Page 2