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HomeMy WebLinkAboutNCC232620_FRO Submitted_20230830 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: PIN 03724101, Mecklenburg County 2. Address of land—disturbing activity: 5201 Victoria Ave, Charlotte, NC 28269 3. Approximate date land-disturbing activity will commence: April 1, 2023 Month Day Year 4. Purpose of Development(Residential, Commercial, Industrial, etc.): Commercial 5. Approximate acreage of land to be disturbed or uncovered: 7.58 acres 6. List total site acreage: 27.59 Ac. 7. Landowners of Record(Use blank page to list additional owners): Name: COUNTRYWOODS COMMUNITY LLC Address: 8480 HONEYCUTT RD STE 200 RALEIGH NC 27615 Telephone: 585-465-0099 Fax: N/A (Area Code) (Area Code) Email Address: kenyon@a kdmdevelopment.com Signature: Name: Kenyon Burnham Address: 8480 Honeycutt Road, Ste. 200 Raleigh, N.0 27615 Telephone: 585-465-0099 Fax: N/A (Area Code) (Area Code) Email Address: kenyon( )kdmdevelopment.com Signature: 8. Indicate Book and Page where deed or instrument is filed(Use blank page to list additional deeds or instruments) Book 12560 Page 227 Book Page Book Page Book Page Page I Continue - Financial Responsibility/Ownership Form PART B 1. Person(s) or firm(s) financially responsible for this land-disturbing activity: Person or Firm: COUNTRYWOODS COMMUNITY LLC Address: 8480 HONEYCUTT RD STE 200 RALEIGH NC 27615 Telephone: 585-465-0099 Fax: (Area Code) (Area Code) Email Address: kenyon(a�kdmdevelopment.com 2. North Carolina agent, for the person or firm who is financially responsible: Person or Firm: Kenyon Burnham Address:8480 Honeycutt Road, Ste. 200 Raleigh, N.0 27615 Telephone: 585-465-0099 Fax: N/A (Area Code) (Area Code) Email Address: kburnha@u.rochester.edu 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.) Kenyon Burnham Vice President - Managing Member Printed Name Title iN/z1 Signature I Date 1 I, _5 l�'1�, ,�€. .-kck \ , a Notary Public of the County of 0 R , State of M oC-Vn C-- AS , hereby certify that KA—Ay o1'1 0-1 V col In ct rs/1 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 day of ,4 f t-in , 20 Notary Signature: � �- My Commission expires: A pc ,N am, a • ................... 01ARLOTTEv = 4-24-2027 = ENGINEERING&PROPERTY MANAGEMENT ,Q Land Development Division ,` „ ,,,,, �4. 600 East Fourth Street, Charlotte,North Carolina 28202-2844 %,,,COUN ;,,0 Telephone: 704/336-6692 Fax: 704/336-6586 http://landpermits.charmeck.org Page 2