NCC222614_FRO Submitted_20220727

May 05 21 05:00p King Residence
7048753499 p.5
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 Mmagement Dgxdment, Land Development Services Division
or Mecklenburg County Land Devcloprment Services. The financial responsibility party will be on turd as the party to
accept any Notices of "Violation or related documents for any non-compliance of the City of Charlotte Soil Erosion aril
Scdimentstion Ordinance. if the financially rmponsiblc party is out of State, a North Carolina agent Yrwt be assigned.
Please Type or Print
PART At
1- Project where land -disturbing activity is to be undertaken: Wadmworth place
2. Address of land —disturbing activity: 200 Wadsworth Place, Charlotte., NC 28206 .
3. Approximate date land -disturbing activity will commence:_ August -AL L p 2021
Month Day Year
4. Purpose of Development (Residential, Cornmc vial, Industrial, etc.): Commercial (Multl4wrnily)
S. Approximate acreage of land to be disturbed or uncovered: 5-813 ac
6. List total site acreage: 6.08 sc
7. Lndovmers of Record (Use blank page to list additional owners):
Name: Reid, Lisa P Reid
10425 Mt. Holly Huntersville Rd, Huntersville, NC 28078
Ck 1 I (rD ,
(Area Code) tAr" rnrw
Email Address: II 5 Q 9.0 A. �, cprr or �talck W
Signature: 9 - kzQ5 } S
Name: Don R Reid (See PG 2)
Address:
'telephone: Fax:
(Area Cock)
Email Address:
Signature:
r-
(Area Code)
8. indicate Boot and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 05378 Page W Book:__ . _ Page
.hook Page Book _ Page
Page i

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: Wadsworth Place
2. Address of land —disturbing activity: 200 Wadsworth Place, Charlotte, NC 28206
3. Approximate date land -disturbing activity will commence: August 01 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.,._ (Multi -family)
5. Approximate acreage of land to be disturbed or uncovered: 5.88 ac
6. List total site acreage:
5.08 ac
7. Landowners of Record (Use blank page to list additional owners):
Name: Lisa Reid (See PG 1)
Address:
Telephone:
(Area Code)
Email Address:
Signature:
Name: Don R Reid
Fax:
Address: 10425 Mt. Holly Huntersville Rd, Huntersville, NC 28078
Telephone:
(Area Code)
Email Address:
Signature: _,(1517
(Area Code)
Fax:
(Area Code)
(Don Reid)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book— 05378
Page 843
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: 200 Wadsworth Apartments LLC
Address: 1420 Spring Hill Road, Suite 420, McLean, VA 22102
Telephone: [phone]
ax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Capitol Corporate Services, Inc
Address: 120 Penmarc Drive, Suite 118, _
Raleigh, NC 27603
Telephone: [phone]
(Area Code)
Email Address: arickettsPia0c.com
ax:
(Area Code)
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.)
Gregory G. L34EVP
Printed N.Ze Title
bt(
Date
a Notary Public of the County
of State of hereby
certify that
appeared before me this
Witness my hand and no
Notary Signatt -`"
My Commi 'on expires.
personally
and under oath acknowledge that this form was executed by him/her. nn
rl seal, this _ I 'Z�_ day of - , 20 0�
Z . - s '7
DEBRA LEIGH WEST
NOTARY PUBLIC
REGISTRATION # 7803603
COMMONWEALTH OF V!RGINIA
MY COMMISSION EXPIRES
APRIL30,2022
(:FIARLMTE
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http : Hlandpermits. charmeck. org
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