NCC223915_FRO Submitted_20221122

City of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity oil 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 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. All relevant
items on this form must be f llcd out accurately and completely
Please Type or Print
PART A
1. Project name: 6859 SB, LLC
2. Address of land —disturbing activity: 6859 South Blvd
3. Approximate date land -disturbing activity will commence: NOV
Month
4. Purpose of Development (Residential, Commercial, Industrial, etc.):
5. Total acreage of land to be disturbed or uncovered: 1.06
Cl
List total site acreage: 0 . 96
01
Day
Office
2022
Year
7. 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:
0
Name: 6859 SB, LLC
Address: 4024 Triangle Dr
Charlotte, NC
Telephone:
Email Address:
Name:
Address:
414.342.4050
Fax:
(Area Code) (Area Code)
[e-mail]
Telephone: Fax:
(Area Code) (Area Code)
Email Address:
Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 36683 Page g 4 5 2 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: If the financially responsible
person(s) orfirm(s) has an out-of-state address, a North Carolina agent must be designated in item 2 below):
Person or Firm:
6859 SB, LLC
Address: 4024 Trian le Dr
Charlotte NC
Telephone: [phone] Fax:
(Area Code) . (Area Code)
Email Address: [e-mail]
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 Firm:
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
financially responsible company or entity, if not an individual.)
Jessica Graham Owner Representative
Printe me Title
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gnature Date
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certify that4""� personally
appeared before me this day and under
Witness my hand and notarial seal, thy
Notary Signature:
My Commission expires:
owledge that this form was executed by him/her.
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charlottenc.gov
Storm Water Services — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone: [phone]
http'//charloUenc.ov/developmentcenter
Rev. 09/2021
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