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HomeMy WebLinkAboutNCC222987_FRO Submitted_20220823City 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 parry 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: The Pearl: Charlotte Innovation District Phase 1A Demolition and Early Grading, Design Package 1-1 2. Address of land —disturbing activity: 801 S McDowell St, Charlotte, NC 28203 3. Approximate date land -disturbing activity will commence: 07 Month 4. Purpose of Development (Residential, Commercial, Industrial, etc.) 5. Total acreage of land to be disturbed or uncovered: 17.5 acres 6. List total site acreage: 17.5 acres 05 2022 Day Year Commercial 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: Charlotte Mecklenburg Hospital Authority Address: PO Box 36022, Charlotte, NC 28236 Telephone: (704)-607-7428 Fax: (Area Code) (Area Code) Email Address: Shelley.Clontz@atriumheaIth.org Additional Properties: Parcel ID Owner Legal Reference , 25 i l5,',_'; h^, iyScp"j`..+'d�.p '-'_C �6885- : 5 Z252C.55 CFaronc er,n r HoswA_rr-•y -q 15 22, 12520151' C _ar:ce ' uienb rg Hos a: ,r:orr,=y Sn-Sb 12520150 oc+-.a, : "•.=ruL—r-•;es. _LC 35267-192 252,158 .0okol.;.,_LC _7T 352e -<97 — 1 8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or instruments) Book See Above page See Above 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: ff the financially responsible person(s) or firm(s) has an out-of-state address, a North Carolina agent must be designated in item 2 below): Person or Firm: Atrium Health Address: 1300 Blythe Blvd, Charlotte, NC 28203 Telephone: (704)-607-7428 Fax: (Area Code) (Area Code) Email Address: Shelley.Clontz(abatriumhealth.com 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 F 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.) kib A Aaw'yoryt 1%i'c e pyf-S i d co of 0 7'l r� �'Ssf'w;�' Printed Name Title Signature 4 1! Date a Notary Public of the County State of-�� g ; hereby certify that i t,� ca ,,� VYl i� ti) 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 g day of_ r , ( 20 Z ZZ Notary Signature: My Commission expires: Gq TA EXPIRES _ G E CR IA APR 9, 2022 - - � ............... . charlottenc.gov '%/1,111CI�I,��1Storm Water Services- Land Development 600 East Fourth Street, Charlotte, North Carolina 28202-2844 Telephone: 704/3 3 6-6692 Rev. 09/2021 ;tttp:/icharI ` - ioprnentcenter Page 2