NCC222898_FRO Submitted_20220818

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:
MADISON ASHLEY PARK APARTMENTS
2. Address of land —disturbing activity: 2400, 2402, 2424, 2440, 2444 WILKINSON BLVD, 2433, 2439, 2443 ARTY AVENUE
3. Approximate date land -disturbing activity will commence:
Month
4. Purpose of Development (Residential, Commercial, Industrial, etc.):
5. Approximate acreage of land to be disturbed or uncovered: 5.30 AC
6. List total site acreage: 4.70 AC
7. Landowners of Record (Use blank page to list additional owners):
Name: MADISON ASHLEY PARK OWNER, LLC
Address: 6805 MORRISON BLVD, SUITE 250
CHARLOTTE, NC 28211
Telephone: [phone]
(Area Code)
Email [e-mail]
Signature:
Name:
Address:
Telephone:
Email Add
Signature: _
(Area Code)
Fax:
Fax:
APRIL 1, 2022
Day
RESIDENTIAL
(Area Code)
(Area Code)
Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 36329 Page 77 Book 36329 page 069
Book 36329 page 556 Book 36329 page 560
BOOK: 36329 PAGE:73
Year
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Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: MADISON ASHLEY PARK OWNER, LLC
6805 MORRISON BLVD, SUITE 250
CHARLOTTE, NC 28226
Telephone: [phone]
(Area Code)
Email Address: [e-mail]
Fax:
(Area Code)
2. North Carolina agent, for the person or firm who is financially responsible:
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.)
50e Teaaai
Printed N
Frei I A', r
Title
L. 1-zz
Date
I, IiG L tAT-L*-Y— , a Notary Public of the County
of Q_s. _V'U 'r State of hereby
certify that 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
Notary Signature. -
My Commission expires.
3t
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day of_'_jC4.ny" 20 as
•
CHRRMTTE.
ENGINEERING & PROPERTY
MANAGEMENT
n. r roil!
M I TCt,
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://Iandpermits.charmeck.org
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