NCC221853_FRO Submitted_20220516

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 Count- Land Development Sen•iees. 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 part' is out of State, a North Carolina agent must be assigned.
Please Type or Print
PART A
1. Project where land -disturbing activity is to be undertaken: VLResidences
1 Address of land -disturbing activity:
( l't 2S �cLti-cde,f�P. is -�.-�-er•b r�ate(�c�cs aSstigK[d� � N��<.(� Cati+v4h� ��a�,r�ss►n�)
3. Approximate date land -disturbing activity will commence:
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 1.48 ac.
6. List total site acreage: 1.694
Landowners of Record (Use blank page to list additional owners):
Name:
Addres
Telephone: q 01 (041 5Co Q q) Fax:
Email Add
Signature-
Name -
Address:
Telephone: Fax:
(Area Code) (Area Coco)
Email Address:
Signature:
Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book G � —Page 5q Book Page
Book Page Book Page
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm:_
Address: SBii:)
Telephone: D A 9 Fax:
(Area Co(k) (Area Code)
Email Address: man D.C� n o r M
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
i Telephone:
(Area Code)
Email Address:
(Area Code)
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.)
02
Printed
Signature
rY} 0.Yl o� Q S n S tl'��c•rti �.�f_
Title d
Date
1. ____ __ _. a Notary Public of the County
Of Ke P,n c State of &2r-lti, arb l A hereby
cert7fy that r� [' � _. Sa L, ._ personally
appeared before me this day and tinder oath acknowledge that this form was execrated by him/her.
Witness my hand and notariu,/r eal, this day of __ � Zp
1
Notary Signature:
My Commission expires: 9' 4-7 • 2-0 2-5
OFFICIAL SEAL
, Notary public, North Carolina
County of Mecklenburg
[(4
-= STACY WEIS
Q�UtCATTE.
ENGIpEEIUliG k Rl4RlfT1'
MApAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax:[phone]
http:lAandpermits.channeck.org