NCC230781_FRO Submitted_20230323

City of Charlotte Soil Erosion and
Sedimentation
Control Ordinance
Financial Responsibility/Ownership Form
No person shall initiate any land -disturbing activity on 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 mast be assigned. All relevant
items on. this form must be filled out accurately and completely
PART A
l . Project name.
Please Type or Print
Charlotte Country Day School
2. Address of land —disturbing activity: 8198 Fairview Road, Charlotte, NC, 28211
3. Approximate date land -disturbing activity will commence: March 1, 2023
Month lea Year
4. Purpose of Development (Residential, Commercial, Industrial, etc.): Commercial
Total acreage of land to be disturbed or uncovered: 4.95 acres
6. List total site acreage. 58.7 acres
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. Charlotte Country Day School, Mr. Greg Walters, Facilities Director
. 8198 Fairvview Road, Charlotte, NC, 28211
TeIephon.e: 704-9434636
(Area Code) (.Area Code)
Email Address: greg.walters a charlottecountr yda .or
Name:
Address. -
Telephone:
(Area Code)
Email Address:
Fax:
(Azea Code)
8. Indicate Book and Page where deed or instrument is filed (Use blank page to list additional deeds or
instruments) Book 02024 Page
Book Page
021
Book Page
Book: Page
Page ]

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land -disturbing activity {Note: If'thc° manelalij, responsible
pers;oa(.$) os firm(s) has an out -of -.state address, a North Carolina agent must be designate) in item ? below):
Person or Firrn�Charlotte Country Day School, Mr. Greg Walters, Facilities Director
Address--8198 Fairview Road, Charlotte, NC, 282I I
Telephone- 704-9434636
(Area Code j (Area Code)
Email Address: greg.walters(a',,charlottecountryday.org
.Fax:
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 F
Address:
Telephone:
(Area Code)
Email Address:
X:
(Area Code)
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.)
Mr. Greg Walters
Printed
Title
Facilities Director
hignn-at7ur& ' ! / Date
;Z,rV • �+-i4'� _ a Notary Public oj the Countv
of Gietr�in/bwra..f. State of ka �herebv
cert0i that 6A&r&— o wgar*'Vws ersonal1v
appeared before me this dal and under oath acltnmvledge that this form was executed by him, her.
Witness my nand and notarial seal, this Z.7 4144.
day of wev 20 Z3
Notary Signa re: 1_/��
My Commission avpires._ 8/IZZGZ S—
4 "1
QP NOTAR)-
=� PUBLIC z�
charrlottenc.gov
Storm Water 5ervi.;es — Land Development
600 East Fourth Street, Charlotte, North Carolina 28202-2W
Telephone: 704, 336-bb92
http•, Clrl arlottene_goNs �de�•Llopnietiteenter
Rev. N 2021 Page