NCC230268_FRO Submitted_20230131

City of Charlotte& Mecklenburg County
Soil Erosion and Se1imen0liwai
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: Stratford Richardson YMCA - Clinic
2. Address of land —disturbing activity: 1946 West Boulevard, Charlotte, NC 28208
3. Approximate date land -disturbing activity will commence: January 1 2023
Month Day Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): YMCA to remain, Health Clinic + parking
5. Approximate acreage of land to be disturbed or uncovered: 1,14 AC
6. List total site acreage: 10.44 AC
7. Landowners of Record (Use blank page to list additional owners):
Name: Young Men's Christian Association of Greater Charlotte
Address: 400 East Morehead Street, Charlotte, NC 28202-2606
Telephone: [phone]
(Area Code)
Email Address: lon•bontrac
Signature:
Name:
Address:
Fax:
(Area Code)
D_ymcacharlotte.org
rq Die ems.
l � � � ,,. .,,,...,. Fax:
Telephone: �0�'{- �1 ,r .......,.._
(Area Code) (Area Code)
Email Address:
Signature:
8. Indicate Boole and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 13633 Page 368
Book
13633
Page 866
Book
13633
page 860
Book
13633
page 850
Book
13633
Page 863
Book 13633 Page
853
Book 13633 Page 847
Book 13633 Page 857 P,el
Book 13633 page 844

Continue - Financial Responsibility/Ownership Form
PART B
l . Person(s) or firm(s) financially responsible for this land -disturbing activity:
Person or Firm: Young Men's Christian Association of Greater Charlotte
Address: 400 E. Morehead St. Charlotte NC 28202
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm:
Address:
Telephone:
(Area Code)
Email Address:
ax:
(Area Code)
3. The above information is true and correct to the best of my knowledge and belief and was provided by the
while tinder oath. (This form mast 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.)
j D (A wKai.-, &:� V�, &a � �_SAA
Printed Naive Title
Signature
I,
z� z
Date
t a Notary Public of the County
Qf �ft?c141 k ,rs State of k6r4l, CoroLrie hereby
certify that nnaikan ZnvtA-v-rn4e,,- personally
appeared bgfore me this day and tinder oath acknoivledge that this form ivas executed by hinrlher.
Witness my hand and notarial seal, this Z'2. day of t J Q.C.. ?o2z ,..........__
Notary Signature: -------
rIaIIAtii
My Colnrnission expires:
ENGINEERING & PROPERTY
MANAGEMENT
!!!! ICe I l�Flll! ill I!F idt�ti
Land Development Division
600 East Fourth Street, Charlotte, North Carolina 28202-2844
Telephone:[phone] Fax: [phone]
littp://Iandperinits.charmeck.org
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