NCC223607_FRO Submitted_20221020

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity coveted 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 Meeklenburg 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: PIN 03724101, Mecklenburg County
2
Address of land —disturbing activity: 5201 Victoria Ave, Charlotte, NC 28269
3. Approximate date land -disturbing activity will commence: December 1, 2021
Month Day
4. Purpose of Development (Residential, Commercial, Industrial, etc.,. Commercial
S. Approximate acreage of land to be disturbed or uncovered: 5.03 acres
6, mist total site acreage;
27.59 Ac.
7. Landowners of Record (Use blank page to list additional owners):
Name: COUNTRYWOODS COMMUNITY LLC
Address: 8480 HONEYCUTT RD STE 200
RALEIGH NC 27615
Year
Telephone:585-4fi5-0099 Fax: NIA
(Area Code) (Area Code)
Email Address:kenyonQkdmdOpMent.com _
Signature: _ __—
Name: Kenyon Burnham
Address: 8480 Honeycutt Road Ste. 200
Raleigh, N.0 27615
Telephone:�585-465-0099 Fax: NIA
(Area Code) (Area Code)
Email Address:[e-mail]
Signature: —
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 12560 .- Page
Book Page- _
227
Book Page
Boob Page
Pap 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: COUNTRYWOODS COMMUNITY f_LC
Address: 8480 HONEYCUTT RD STE 200
RALEIGH NC 27615
Telephone: [phone] l-ax:
(Area Codc)
Email Address: ken on kdmdeyelo ment.com
(Area Code)
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm
Address: 8480 Hone cuff Road Ste. 200
Raleigh, N.0 27615
Telephone: [phone] Fax: N/A
(Area Cade) (Area Code)
Email Address: [e-mail]
3. The above information is true and correct to the best of my knowledge and belief and was provided by the
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.)
Kenyon Burnham
Printed Name
signature —
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Cell
Vice President - Managing Member
Title
appeared before ane this day and under oath acknowledge that this fibrin was executed by hina/laer.
Witness nay !rand and n ai irai Sal, thi �i�'% drty Of �; � __ __ . 20..
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time
a Notary Public of the County
hereby
Personally
11,22
0 KAYLA DOBSON
NOTARY PUBLIC
Durham County
North Carolina
CRARLUj" L' I My Commission Expires I?W2426
MONEMM 6 PROMM
MA.MUMEW
Land Development Division
600 East fourth Street', Charlotte, North Carolina 28202-2844
Telephone_ 7041336-6692 Fax: [phone]
http,Nlandpermits.charmeck_org
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