NCC223186_FRO Submitted_20220912

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: CONCOURSE II
2. Address of land —disturbing activity: 9320 PORTERS VIEW DRIVE, CHARLOTTE, NC 28273
3. Approximate date land -disturbing activity will commence: MARCH 15, 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.):_ INDUSTRIAL
5. Approximate acreage of land to be disturbed or uncovered: 19.80 ACRES
6. List total site acreage: 20.061 ACRES
7. Landowners of Record (Use blank page to list additional owners):
Name: CONCOURSE INDUSTRIAL, LLC
Address: 301 S COLLEGE ST, STE 2800, CHARLOTTE, NC 28117
Telephone: [phone] Fax:
(Area Code)
Email Address: Jon.Wilson(a�childressklein.com
Signature:
Name:
Address:
(Area Code)
Telephone:(3 o#',a 3 $3 - t3 1 1 Fax:
(Area Code) (Area Code)
Email Address:
Signature:
8. Indicate Book and
instrument is filed (Use blank page to list additional deeds or
instruments) Book 35849 Page 311
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:
Person or Firm: CONCOURSE INDUSTRIAL, LLC
Address: 301 S COLLEGE ST, STE 2800, CHARLOTTE, NC 28117
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: Jon.Wilson&childressklein.com
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Same as above
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
financial responsible company or entity, if not an individual.) rt
(: r� 4—� :1)' C
Printed Name Title
9fr? �Z
Signature Date
I,Law rel 5-prummo a Notary Public of the County
of Me o lde n ktAn I State of Norih hereby
certify that _Chlj sa� o6tsr T 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 q day of Pvh rii A n \/ 20 as
Notary Signature: VAjmM JA'
My Commission expires: 01115iaoa5
JQ Notary Public Z
�T Mecklenburg
�.�'TE_
'' County =
P:iy C m
ENGINEERING & PROPERTY
'/'�•,oRTN'
Land Development Division
CIA'R`�•�``\
600 East FourthStreet, aro36 202 2844
Carolina
704 336-6692 Faxh 86
http://Iandpennits.charmeck.org
Page 2