NCC232186_FRO Submitted_20230814

City of Charlotte & Mecklenburg County
Soil Erosion and Sedimentation
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: Publix at Carmel Commons
2. Address of land—disturbing activity: 11525 Carmel Commons Blvd., Charlotte, NC 28226
3. Approximate date land-disturbing activity will commence: November 1 2022
Month Day Year
4. Purpose of Development(Residential, Commercial, Industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncovered: 6.01 AC
6. List total site acreage: 4.475 AC
7. Landowners of Record(Use blank page to list additional owners):
Name: Publix North Carolina LP
Address: 3300 Publix Corporate Parkway, Lakeland, FL 33811
Telephone: [phone] Fax: n/a
(Area Code) (Area Code)
Email Address:[e-mail]
Signature: _
Name: MKC Holdings LLC
Address: 6812 Thorton Oaks Ct.. Charlotte, NC 28270
Telephone: _ Fax:
(Area Code) (Area Code)
Email Address:
Signature:
8. Indicate Book and Page where deed or instrument is filed(Use blank page to list additional deeds or
instruments) Book 24 Page 916 Book 53 Page 757
Book 31820 Page 145 Book 28825 Page 1
Page 1

Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: Publix North Carolina LP
Address:3300 Publix Corporate Parkway, Lakeland, FL 33811
Telephone:[phone] Fax: n/a
(Area Code) (Area Code)
Email Address:Bridgid.Oconnor©publix.com
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: INAL MOVOiOlf (,d1Y1�0YlitaS
Address: 14521 511iYon td suitL a'45, OnoxIo.44,, NC 21211
Telephone(T A) %CI— 4500 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.)
Bridgid A.O'Connor Vice President Real Estate Strategy
Printed Name Title
Signature Date
Jessica Hernandez , a Notary Public of the County
of Polk , State of Florida , hereby
certify that Bridgid A.O'Connor,Vice Pesident Real Strategy personally
appeared before me this day and under oath acknowledge that this form was executed by him/her.
Witness my hand and notarial seal, this I I day of JV t,], , 2023
Notary Signature: O ttet-. UU
My Commission expires: A?(2,1 1 " t 202 C.9 �.
•
(CIX
ENGINEERING I PROPERTY
MANAGEMENT
Land Development Division
600 East Fourth Street,Charlotte,North Carolina 28202-2844
Telephone: [phone] Fax: 704;336-6586
http://landpermits.charmeck.org
Page 2

7. landowners of Record(Continued)
Name: Woodle Properties LLC
Address:
6625 Carmel RdL Charlotte, NC $226
Telephone:7a ".r74///74"8 Fax:
Ematl Address: ODdjL OD nCS4µ` sC!'td CC c- —
Signature: �(
Name: Carmel Crossing LLC
Address: 1370 Jet Stream Dr.Ste 100 Henderson NV 89052
Telephone: T) ' Le ' L{ -{ ("oe Fax:_ -
Email Address: (*,:J1) jlAjt!►".4 ? _ VI `. I u►_ (ti 2( t L-— •
Signature:
Name: Carmel Road Reelity Partners, LLC
Address: t0tN- t nettsN f ,71 h�C).Mar 4 me
[cc rro. 1; 151k4 e ' )r r 1c-';t° n C
Telephone: 70 4-410 Fax:
Email Address:
Signature: _
8. Indicate Book and Page whore deed or instrument is Pled (Continued)
Book 19 Page 249