NCC222334_FRO Submitted_20220628

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 -disturbing activity is to be undertaken:
Alexander Providence
2. Address of land —disturbing activity: 6623 and 6633 Providence Road
3. Approximate date land -disturbing activity will commence: January 1 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential, multifamily
5. Approximate acreage of land to be disturbed or uncovered: 5 acres
6. List total site acreage: 6 acres
7. Landowners of Record (Use blank page to list additional owners):
Name: Thomas Edward Kelly Jr.
Address: 6623 Providence Road Charlotte, NC 28270
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Signature:
Name: Lake City Tractor Supply LLC
Address: 131 Providence Road Suite 105 Charlotte, NC 28207
Telephone: "70-tj 07 4 -PO tl0 Fax
Email Address:
Signature:
a-r % d t^ k1r
Av1A
(Area Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 27401 Page
Book 32684 Page
176
828
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: Ifthe financially responsible
person(s) orfrrm(s) has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm:
Address: 227 W Tr de St., Suite 1610
Charlotte. NC 28202
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: wtwiddVadrhgrnup corn
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: Fax:
(Area Code) (Area 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 responsible company or entity, if not an individual.)
Scott Widener
Vice -President
Title
Date
I, Sherry L. Walton _ , a Notary Public of the County
of Lincoln County State of North Carolina , hereby
certify that Scott Widener 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 Le day of April 12022
Notary Signature:
My Commission expires:
W
W Cs3 +CP i+*% r +
Y r
PUB%. z
s
charlottenc.gov
Storm Water Services -- Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
http://cliarlottetic.gov/develoomentcenter
Page 2
Rev. 09/2021