NCC230814_FRO Submitted_20230323

City of Charlotte Soil Erosion and
Y
Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity on one or more acres as covered by Cbapter 17 of the Charlotte
City Code of Ordinances before this form and an acceptable cresion and scdirnentation 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-ertttpliance of the City of Charlotte Soil Erosion and Sedimentation
Ordinance. if the fiinanclatly responsible party is out of State, a North Carolina agent must be assigned. All relevant
items on this form must be filled out accurately and corapIctely
Please Type or .Print
PART A
1. Projectname. .Albemarie Road Aspen Dental
2. Address of land disturbing activity: 8813 Albemarle Road
Charlotte, NC 28227
3. Approximate date land -disturbing activity will cornimi1cc: 11 is 2022
Month Day Year
4. Purpose of Development (Residential, Commercial, industrial, etc.): Commercial
S. Total acreage of land to be disturbed or uncovered: 1.20
& List total site acreage:
O.72
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:
Name: Becton Partners, LLC
Address: PO Box 1392
Cornelius. NC 28031
Telephone: [phone] Fax:
[Area Code] (Area Code)
Finail Address: watson(a oysterdvp.corn
Name:
Address:
Telephone:_
Email Address:
ax:
(Area Cock) T (Arta Codc)
8. Indicate Book and Page where deed or inmiment is filed (Use blank page to list additional deeds or
instruments) Book 37463 Page 238 Book__ .Page
Book Pagc Book Page
rav I

Continue - Financial Responsibility/Ownership Form
PART S
1. Person(s) or, firms) financially responsible for this land -disturbing activity(Note: ljthc jrlonedally responsible
person(s) orfrm(s) hay an out-of-state address, a lVarih Carmine agent must be designated in uem 2 below):
Person or Firm. Becton Partners, LLC
Address: PO Sox 1392
Cornelius, NC 28031 _
Telephone: OAT 4) 906-4491 _ Fax:
{Arcs Code} (Area Code)
Fniail Address: [e-mail]
2. 1f the .Financially Responsible Parry is not a resident of . ordi Carolina, givc narne and street address of the
designated North Carolina agent.
Person nr Firm:
Telephone:
(Area Code)
Email Address:
ax:
(Area Lucky
3. The above information is true and confect 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.)
f A. �'�+L+Lrs4CJ
Printed Name Title
of
certi,& Ihat rr
appeared before tyre this day
Vamers my hand and
Notary Signature. -
My Commission expires:
I a 77'
State of r-I �v
7_T.SOft
under oath ackrtowioge that rhr; formr�was executed by hirrtrher.
th s• a� sti
MICHAI-[- R TOURTELOT
NOTARY PUBLIC
Mec%'.enbarg County. Nora+ Caloiira
>My Commission Expires 3118126
charlottenc.gov
Storm Water Services -- Land pcelopment
600 East Fouril7 Street. [Marlette, North Carolina 29202,2844
Telephone. 704t336-66=12
httn:l;chadotlene.eovldevelopmcnloca ter
Rev. MM t
2 it
E
Pubdie of the County
, hereby
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Prge 2