NCC223134_FRO Submitted_20220906

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: 08116106, 08116109, 08116107, 08116108
& portions of 08116103, 08116105, & 08116110
2. Address of land —disturbing activity: 1219 E. 16th St. Charlotte, NC 28205
3. Approximate date land -disturbing activity will commence: 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 1.43 ac
6. List total site acreage: 1.285 ac
7. Landowners of Record (Use blank page to list additional owners):
Name: JsH Development LLC
Address: 1616 Cleveland Ave. Charlotte, NC 28203
Telephone: —7°q ` 8o S r -fg utl Fax:
(Area Code) II
Email Addressn b h�i�iratr
Signature:
Name: Hawthorne Mill Partners LLC
: 6101 Preston Ln. Charlotte, NC 28270
Telephone: Fax:
(Area Code)
Email Address:
Signature:
(Area Code)
krr I
aianir i'tlrin ✓%� In ram.- �" r t r i GJri.<.
(Area Code)
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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, ]f 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: 08116106, 08116109, 08116107, 08116108
& portions of 08116103, 08116105, & 08116110
2. Address of land —disturbing activity: 1219 E. 16th St. Charlotte, NC 28205
3. Approximate date land -disturbing activity will commence: 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 1.43 ac
6. List total site acreage: 1.285 ac
7. Landowners of Record (Use blank page to list additional owners):
Name: JBH Development LLC
Address: 1616 Cleveland Ave. Charlotte, NC 28203
Telephone: Fax:
(Area Code)
Email Address:
Signature:
Name: Hawthome Mill Partners LLC
Address: 6101 Preston Ln. Chadotte, NC 28270
(Area Code)
Telephone: Fax:
(Area Code) (Area Code)
Email
Signav
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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: JBH Development LLC
Address: 1616 Cleveland Ave. Charlotte NC 28203
Telephone: [phone]
(Area Code)
Email Address: [e-mail]
(Area Code)
2. North Carolina agent, for the person or fnr1n who is financially responsible:
Person or Firm:
Address:
Telephone:
(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 resporlsq)le company or entity, if not an individual.)
T (_�a (I
I,
Of uy/o
K_
&!A ,I If
Title
� G I� 1
Date
a Notary Public of the County
State of A/" hereby
certify that \=2-7 Al77 Yk personally
appeared before me this day and under oath acbiowledge that this form was executed by him/her.
Witness my hand al�otarjl ,pal, this e7_1 , day of �S OC40148 67Z 20 611
Notary Signature:
My Commission expires: 0 0xO Q4EK -- Q- � 0 a A
l heresa t<. 91um
�
Notary Public
Union County
North Carolina
My Commission F�cpires 10 21 2022
�r
CHARLOTTE
ENGINEERING & PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:[phone] Fax:[phone]
http://Iandpermits.charmeck.org
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