NCC232093_FRO Submitted_20230720

„ . ,, . Mecklenburg County Soil Erosion and
, Sedimentation Control Ordinance
�,`411i,rt�t1i^ , Financial Responsibility/Ownership Form
No person shall initiate any land-disturbing activity covered by Section 6 of the Mecklenburg
County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to
completing and filing this form with Mecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documents for any non-compliance with the above Ordinances. If the
financially responsible party is out of State, a North Carolina agent must be assigned.
Please Type or Print
PART A
I. Project where land-disturbing activity is to be undertaken:
"Brooklyn Village South” Bob Walton Plaza at McDowell/Stonewall/Alexander
2. Address of land-disturbing activity:
600 E Stonewall Avenue
3. Approximate date land-disturbing activity will commence: January 30 2022
Month Day Year
4. Purpose of development(Residential, Commercial, Industrial, etc.): MIXED USE
5. Approximate acreage of land to be disturbed or uncovered: 6.5 ac
6. Total site acreage: 5.95 ac
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner#1 Name: Mecklenburg County
Address: 600 E 4th St 11th Floor Charlotte, NC 28204
Telephone: 704 - 336 - 7600 Fax:
Email Address: [e-mail]
Owner#2 Name:
Address:
Telephone: Fax:
Email Address:
8. Indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 07781 Page 627 Book Page
Book 31034 Page 331 Book Page
(continue on back or separate pages as necessary)
Fonn Revised 12-2016

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: BK Partners LLC - R. Donahue Peebles
Address: 5937 Collins Avenue Miami, FL 33140
Telephone: [phone] Fax:
Email Address: [e-mail]
2. North Carolina agent for the person or firm who is financially responsible:
Person or Firm: Conformity Corporation - Monte Ritchey
Address: 1001 Elizabeth Avenue, Suite 1C, Charlotte, NC 28204
PO Box 33218
Telephone: [phone] Fax:
Email Address: [e-mail]
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.)
R. Donahue Pe I s Member
Printed ame449/\--- Title
- 2P-
)nature Date
l kei i. 't t Ilk , a Notary Public of the
County of IVY I/kir , State of FLO 7--PA- , hereby
certify that p J4 tar IA w re e-( l-F S personally appeared
before me this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial s 1, t is AP> day of —.1ic?V1A4 , 20 at .
NotarySignature:g =a•�r•, Euaw IZQUIERDO III
My Commission expires: , Commission#GG122116
expires November 5,2021
Bonded Mu Troy Fain Insurance 800-385-7019
Mecklenburg County Land Use and Environmental Services Agency
2145 Suttle Ave.
Charlotte.NC 28208-5237
Phone[phone]