NCC222795_FRO Submitted_20220825

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. Thefinancial 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 fmancially 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: Prose Rhyne
2. Address of land —disturbing activity: 0 Mount Holly Road, Charlotte, NC
3. Approximate date land -disturbing activity will commence: April 1, 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered:18.00 AC
6. List total site acreage: 25.77 AC
7. Landowners of Record (Use blank page to list additional owners):
Name: RSI Land Holdings LLC
Address:608 Briar Patch Terrace, Waxhaw, NC 28173 .
Telephone: [phone]
Email
Signat
Name:
Address:
Fax:.
Telephone: Fax;
(Area Code) (Area Code)
Email Address:
Signature:
8. Indicate Book and Page where deed or instrument is filed (U:e blank page to list additional deeds or
instruments) Book 35409 page 629 Book Page
Book 35409 page 633 Book Page
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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: Prose Rhyne Alliance, LLC
Address: 200 Providence Road, Suite 250
Charlotte, NC 28207
Telephone: [phone] Fax:
(Area Code)
Email Address: [e-mail]
(Area Code)
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Fi
Address:
Telephone: Fax:
(Area Code)
Email Address:
(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.)
Printed
Signature
Title
11 s�i /Z02-1
Date
a Notary Public of the County
Of P�c�e••�v-�q_ State of v tx" r� C , hereby
certify that ti 6 S personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notar�l seal, this a _ day of O,, e,)*-� 20
ZN
Notary Signature: l �,it?d''CQ�.,r fZi'-
My Commission expires: 1�4� — ad 3
•
�M. HOWE
PUBM
MECI( MWRG COUNTY, NC
NV CAm*WM Expirea 7 2s-2oz3
ENGINEERW6 �PROPEIIIY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Teiephone:704/336-6692 Fax:[phone]
http:l/landpermits.charmack.org
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