NCC222124_FRO Submitted_20220608

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 patty 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: GRIFFITH LAKES PH2
2. Address of land —disturbing activity: 4701 W.T. HARRIS BLVD (PID: 04306202)
CHARLOTTE, NC 28269
3. Approximate date land -disturbing activity will commence: 07 01 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Total acreage of land to be disturbed or uncovered: 50 AC
6. List total site acreage: 357.81 AC
7. Landowners of Record (attach accompanied page to list additional owners). If the landowner of record is not
the person(s) or firm(s) financially responsible as listed in Part B, item 1, a separate letter of consent signed
by the landowner of record or their authorized agent is required:
Name: HARRIs WOODS LLC
Address: 1944 BRUNSWICK AVE SUITE 2A
CHARLOTTE, NC 28207
Telephone: [phone] pax:
(Area Code)
Email Address: ,[e-mail]
Name:
Address:
Telephone: Fax:
(Area Code)
Email Address:
(Area Code)
(Area Code)
8. Indicate Boole and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 15269 Page 191 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 (Note: If the financially responsible
person(s) or firm(s) has an out-of-state address, a North Carolina agent must be designated in item 2 beloiv):
Person or Firm: Toll Southeast LP Company, Inc.
Artriraee. 14529 GRAND PALISADES PARKWAY
CHARLOTTE, NC 28278
Telephone: [phone] Fax:
(Area Code)
Email Address: JPOU@TOLL BROTH ERS.COM
(Area Code)
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:
Address:
Telephone:
(Area Code)
Email Address:
Fax:
(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.)
JAMIE POU DIVISION PRESIDENT
Printed N6' ' > Title
�i
,S`i ature Date
'gin.
LAPP PCZIVE7E a Notary Public of the County
Of DNIy iD5jDl1 State of Q001A CP,2k3UkAN . hereby
eertify that, J 01ME 9W personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this day of APQ.\L 20
Notary Signature:
My Commission expires: n,
KALYN LAPP PRIVETTE
Notary Public, North Carolina
Davidson County
My Commission Expires
May 25, 2025
9M
char[ottenc.gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 29202-2844
Telephone: [phone]
http:1/charlottenc. p-ov/developmentcenter
Rev. 0912021 Page 2