NCC221923_FRO Submitted_20220524

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 parry 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: PIN: 16307131, 18903440, & 18902501, on the
on the east and west side of Rama Road on both sides of the CSX railroad right-of-way
2. Address of land —disturbing activity: 1733 Rama Rd
Approximate date land -disturbing activity will commence: March 1, 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
Approximate acreage of land to be disturbed or uncovered:
6. List total site acreage: 9.74 AC
3.00 AC
7. Landowners of Record (Use blank page to list additional owners):
Name: Carolina Cottage Homes LLC
Address: 2550 West Tyvola Rd., Ste. 100, CLT 28217
Telephone: [phone]
Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Signature:
Name: PeterT. Harakas, VP
Address: same
Telephone: Fax:
(Area Code)
Email Address:
Signature:
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 07606 Page
Book Page
517
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: Carolina Collage Homes LLC
Address: 2550 W. Tyvola Road, Suite 100, Charlotte, NC 28217
Telephone: [phone] Fax:
(Aria Code) (Area Code)
Email Address; [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Telephone: Fax:
(Aren Code) (Arco Code)
Email Address;
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 re onsible company or entity, if not an individual.)
Pater .Hat a Vice President
print edNa r— Title
S;gnature JJ l ` ate
1, ( 14 01 P 0) 1 Ir 1 a Notary Public of the Couno,
of State of /yd e F1 C 12-9C "V' hereby
h A -eA&IS Personally
cerlr rthat F� I f=i� /7a ersnnQ71
appeared before are this day and under oath acknowledge that thisform was avaeured +by hfm/her.
Witness my hand and notarial seal, this � ci 4`431 Qf 10 j2 111 h i 20
Notary Signature:
My Commission expires:
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Land Dcvclapmcnt Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax:[phone]
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