NCC222860_FRO Submitted_20220810

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 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. All relevant
items on this form must be filled out accurately and completely
Please Type or Print
PART A
1. Project name: Woodspring Suites
2. Address of land —disturbing activity: 4125 Meadow Oak Drive
3. Approximate date land -disturbing activity will commence: May 1, 2021
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial
5. Total acreage of land to be disturbed or uncovered: 2.45
6. List total site acreage: 2.25
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: Spratt Legacy Partners LLC
Address: 3506 Back Creek Church Road, Charlotte, NC 28213
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Name: Cby)cov-G' (,Q1_ C�AGLI [Ut+- _I LI_(-
Address: La F [ D C'C'eAmoyl �c..L Dri vo a leiai1 N C 0 7 (2 1
Telephone: q i q-�65 — 2 4 U 6 Fax:
(Area Code) (Area Code)
Email Address: . "ke . Y1 C 4e r P LWCDV-00�6N . t r
S. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 28581 page 428
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 Iand-disturbing activity (Note: If the financially responsible
person(s) or firms) has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm: Concord WP COL Charlotte. LLC _
Address: 11410 Common Oaks Drive. Raleieh. NC 27614
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
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
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.)
�.sJ►i t L {� I C�Cti'C�r �, r s_ PMS i s rnr-
Printed Name Title
7/tA1z1
Date
I, (.tiLt.t.� C �M�Glfi� %Am"d& 3VKi fin) , a Notary Public of the County
of � y( .y��ClAV1 State of--Ij ovb6 CxurcuVl0 , hereby
certify that `,S ti C, - ersonally
appeared before me this day and under oath acknowledge that this form was executed by him/her
Witness my hand and notarial seal, this Z?' da �u� 20 Z 2.
,,Y of .
Notary Signature: ..TL
My Commission expires:
charlottenc.gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
http:llcharlottenc. izov/developmentcenter
Rev. 0912021
a W D SR M!T-H
NOTARY PUBLIC
Franklin County
North Carolina
My Commission Expires 06/01/2027
Pave 2