NCC233683_FRO Submitted_20231221

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: 2801 S. Tryon
2. Address of land—disturbing activity: 2801 S. Tryon, Charlotte, NC 28203
3. Approximate date land-disturbing activity will commence: September 1 2023
Month Day Year
4. Purpose of Development(Residential, Commercial,Industrial, etc.): Multi-Family
5. Approximate acreage of land to be disturbed or uncovered: 2.87 AC
6. List total site acreage: 2.38 AC
7. Landowners of Record (Use blank page to list additional owners):
Name: Poindexter Owner LLC
Address: 51 E. 12th Street, 7th Floor, New York NY 10003
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
Signature:
Name: Jesse Wark
Address:
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 332 Page 481 Book 11074 Page 733
Book 17015 Page 309 Book 30434 page 709
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Continue - Financial Responsibility/Ownership Form
PART B
1. Person(s) or firm(s) financially responsible for this land-disturbing activity:
Person or Firm: Poindexter Owner LLC
Address: 51 E. 12th Street, 7th Floor, New York NY 10003
Telephone: [phone] Fax:
(Area Code) (Area Code)
Email Address: [e-mail]
2. North Carolina agent, for the person or firm who is financially responsible:
Person or Firm: Tarlton Long
Address: 1111 Metropolitan Ave. Suite 1035 Charlotte NC 28204
Telephone: [phone] Fax:
(Area Code) (Area Code)
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 foam must be signed by the fmancially responsible person if an individual or by an
officer, director,partner, attorney-in-fact, or other person with authority to execute instruments for the
fmancially responsible company or entity, if not an individual.)
Printed Name Title
7/11)2.3
Signatur Date
I, a Notary Public of the County
of ee' [cs // iti+L)ur , State of , 110 1,1,./ , hereby
certify that / A rZ. / 0 i6/U ( r- personally
appeared before me this day and under oath acknowl dge that this form was executed by him/her.
/
Witness my hand and notar' eal, this day of ��/ 20
Notary Signature:
My Commission expir s: 02 — / --„,,It,„ag
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ENGINEERING&PROPERTY *•. bur C.o' .
MANAGEMENT
Land Development Division
600 East Fourth Street,Charlotte,North Carolina 28202-2844
Telephone: [phone] Fax: [phone]
http://landpermits.charmeck.org
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