Brownfield Grant Program
Application
PROJECT ADDRESS:
Street address, suite number, City, State and Zip
1.
APPLICANT
Legal Name of Applicant:
Mailing Address:
City/State:
Zip Code:
Tax Identification Number:
Website:
If applicant is a business, indicate the business type and attach supporting documentation
(articles of incorporation, etc.):
Corporation
Partnership
Other
LLC
Sole Proprietorship
Are all of Applicant’s local, state and federal taxes current?
2.
Yes
No (provide explanation)
CONTACT INFORMATION (Primary Contact Person for Applicant)
Contact Name:
Title:
Address:
Email:
Primary Phone Number:
3.
PERSONAL BACKGROUND INFORMATION.
The City conducts background checks on all program applicants including all company principals. For
this reason, it is important that the questions in this section be answered completely and truthfully. An
arrest or conviction record will not necessarily disqualify you. An untruthful answer, however, will cause
your application to be denied. Attach additional sheets as necessary.
Provide the full name, birth date (DOB), address and years at address for each applicant and/or
company principal owning more than 10% beneficial ownership if applicant is a company.
Name
DOB
Address*
Years
There
%
Ownership
in
business
*Each Applicant or company principal must provide a list of all of his/her prior addresses for the past five
years including street address, city and state.
Have you ever been charged with or arrested for any criminal offense other than a minor
vehicle violation? (This question must be answered for each Applicant and/or Principal in the
business. All arrests and charges must be explained on an attached sheet including the
outcome of each.)
Yes
Are all personal local, state and federal taxes of each applicant / principal in the business
current? If no, include explanation on attached sheet.
Yes
No
Page 1 of 4
No
3.
PERSONAL BACKGROUND INFORMATION (continued)
List all Mecklenburg County property owned by Applicant and all business principals owning more than 10%
in the business. Attach a separate sheet if necessary.
1.
2.
3.
4.
5.
4.
PROJECT INFORMATION
Project Address:
Tax Parcel Number:
Zoning of Property:
Property Square Footage
What is your legal interest in the building?
Property Owner
Developer (if developer, the property owner must complete an Owner Consent Form)
Are there any known code violations existing at the site?
If yes, explain:
5.
6.
7.
8.
9.
Yes
CURRENT SITE OWNERSHIP
Owner Name
Address (street, city, state, zip):
Phone:
Email:
OWNER’S REPRESENTATIVE
Name
Address (street, city, state, zip):
Phone:
Email:
PROPOSED SITE BUYER
Name
Address (street, city, state, zip):
Phone:
Email:
BUYER’S REPRESENTATIVE
Name
Address (street, city, state, zip):
Phone:
Email:
No
FINAL PROJECT INFORMATION
Provide a brief description of the proposed end-use of the property. Include plans and/or conceptual
information regarding the future use of the property, zoning changes, etc. Use a separate sheet of paper if
necessary. Attach any plans and specs, if available, together with any other related documentation
regarding the site’s proposed future use.
Number of Jobs that will be housed in completed project:
Description of Jobs:
Page 2 of 4
10.
ENVIRONMENTAL INFORMATION
(A) Explain what evidence of suspected – or actual – contamination exists on the site. Use a separate sheet of
paper if necessary. Attach all available supporting reports.
(B) Have any environmental studies on the site been started – or completed – on this project?
If yes, indicate the amount expended to-date on environmental assessment activities: $
(C) Have any cleanup activities already occurred – or been started – on the site?
If yes, provide the amount expended on clean-up activities to-date: $
Yes
Yes
No
No
If yes, provide a description of the cleanup activities and the status of each below, attach all supporting
documentation
(D) Provide an estimate of the number of jobs that will be created by this project:
Construction Jobs
Cleanup Jobs
(E) What is the total estimates construction cost of the project?
11.
BROWNFIELD STATUS
(A) Is the applicant a potentially responsible party that caused or contributed to the contamination to be assessed,
Yes
No
or did the applicant own the property at the time contamination occurred?
(B) Does the property meet the definition of a “Brownfield” as defined in the federal Small Business Liability Relief
and Brownfield Revitalization Act (Section 211(a)(39) of the Public Law 107-118 (H.R. 2869).
No
Yes (STOP - Project may be ineligible)
(C) Does the applicant have or can it obtain access to 100% of the property to be assessed?
Yes
Applicant owns property
Access agreement is in place with current owner(s).
Yes
Presently working on access agreement with current owner(s).
No
STOP – Project may be ineligible
No
(D) Has the applicant received in the past, is it currently receiving, or has it applied for federal, state or local
brownfield assessment or cleanup funding for this property?
No
Already applied for but not currently receiving
federal
state
local
Applied
Currently
receiving
funding
from
federal
state
local
Receiving
List source and activities for which funds were used:
Received in Past
(E) Is the property a former gas station or has it been contaminated by petroleum products only?
Yes
No
Unknown
(F) Indicate the type of work being requested (check all that apply):
Phase I site assessment (cost estimates required)
Phase II site assessment (cost estimates required)
Cleanup (include supporting environmental reports, description of activities and cost estimates)
(G) Is there a specified timeline in which site assessment activities need to be performed?
No
Yes, Please define: __________________________________________
Page 3 of 4
CHECKLIST
Complete this checklist to ensure all required documents are included. Incomplete applications cannot be
considered.
Completed Application.
Organizational Documentation. (articles of incorporation, LLC operating agreement, etc.) (See
Section 1).
Personal Background Exhibits (See Section 3).
Plans and specs or other conceptual designs of proposed end-use of property. (See Section 9)
Copies of all reports addressing environmental conditions at the site. (See Section 10).
Phase I
Phase II
Other ________________________
Check here if not applicable. BY checking here Applicant acknowledges that there have been no
known environmental reports or assessments of any kind conducted as of the date hereof.
Cost estimates Attach two competitive estimates for each expense.(See Section 11F)
Owner Consent Form – Required if Applicant is not the owner of the real estate
Other.
APPLICANT SIGNATURE
By signing below the Applicant acknowledges that he/she has read and understands the program guidelines for the
Brownfield Grant Program available at http://nbs.charlottenc.gov. Applicant understands that costs incurred prior to
application approval and grant contract signing are not eligible for reimbursement. Incomplete applications cannot
be considered. The Applicant authorizes the City of Charlotte to request criminal record information about each
individual or, if Applicant is a Company, each principal of the Company for the purpose of determining eligibility for
this grant. All costs incurred by the City pursuant to this record search will be paid by the Applicant. The Applicant
assures that the information contained in the application is true and correct and agrees to comply with all City of
Charlotte guidelines applicable to this program. The Applicant authorizes the City to use his/her/its name, likeness,
photos and/or information about the project participating in the Program for promotional purposes.
By signing below, the Signatory acknowledges he/she is duly authorized to act on behalf of the Applicant and that
the Applicant is properly organized and licensed to conduct business in the state of North Carolina.
Applicant Name:
Print Name:
Title
Signature
Date
RETURN COMPLETED APPLICATIONS with all required attachments to:
City of Charlotte Neighborhood & Business Services
ATTN: Veronica Williams-Mosley
vmosley@charlottenc.gov
Office: 704.336-2427
600 E. Trade Street, Suite 300
Charlotte NC 28202
Electronic copies are preferred
Page 4 of 4
If the Applicant does not own the property, the below Owner Consent Form must be completed by
the property Owner and submitted with the Application.
OWNER CONSENT FORM
The undersigned owner of the existing property located at
acknowledges that
intends to undertake brownfield assessment and/or cleanup activities at the above property. The
undersigned agrees to permit the Applicant and his/her/its/their contractors or agents to
undertake any and all related activities on the site.
The undersigned hereby waives any claim against the City of Charlotte (“the City”) arising out
of the use of said grant funds for the purposes set forth in the Application. The undersigned
agrees to hold the CITY harmless for any charges, damages, claims or liens arising out of the
Applicant’s activities and participation in the City’s Grant Programs.
In witness whereof, the owner has hereunto set his hand and seal, or if a corporation, has caused
this instrument to be signed in its corporate name by its duly authorized officers and its seal to be
hereunto affixed by authority of its Board of Directors, if a Partnership by its Partners, if a LLC
or LLP, by its Members/Managers, etc. the day and year first above written.
Corporate
Seal
(Company Name)
leave blank if Owner is an Individual
By: __________________________ (Seal)
____________________Name
____________________Title
By: _____________________________ (Seal)
_____________________Name
_____________________Title
NORTH CAROLINA, County of Mecklenburg
I, ___________________________________, a Notary Public, do hereby certify that
______________________________________ personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
WITNESS my hand and official seal or stamp, this ___________ day of ______________,
20_____.
_____________________________
Notary Public
_________________________
My commission expires