NCC232983_FRO Submitted_20231005

wvAxiiiAxv EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
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No person may initiate any land-disturbing activity as defined in Chapter 159 of the Town of
Waxhaw Town Code prior to completion of this form, and an applicable and acceptable erosion
and sedimentation control plan has been approved by the Development Services Department.
(Please type or print)
Part I
Name of Project:Old Town Village
Address where land disturbing activity will take place: 316 N. Providence Street
Waxhaw, NC 28173
Approximate date disturbing activity will commence: 6-1-2022
Purpose of development(residential,commercial, industrial, etc.): Residential
Total acreage of land to be disturbed or uncovered: 9.96 AC
Amount of fee enclosed(show calculation):
Agent to contact should sediment control issues arise during land disturbing activity:
Name: Curt Curtis-Tri Pointe Homes Holdings, Inc.
Address: 6325 Ardrev Kell Rd, Suite 125 Charlotte
State: NC Zip code:28277
Phone: [phone] Email: [e-mail]
Landowner(s):
Name: Refer to Attached Owner Documentation
Address:
State: Zip code:
Phone: _ Email:
Name:
Address:
State: Zip code:
Phone: Email:
Indicate Book and Page where deed of the property where land disturbing activity will take place
is recorded:
Book: 8785 Page: 0758
Book: Page:
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1\ AXIIIIAlv EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
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Book: Page:
Book: Page:
Indicate tax map and parcel number of the property where land disturbing activity will take place
is recorded:
Tax Map: Refer to attached Parcel Information pages Parcel:
Tax Map: Parcel:
Tax Map: Parcel:
Tax Map: Parcel:
Part II
Person(s) or firm(s)who are financially responsible for the land disturbing activity:
Name: Tri Pointe Homes Holdings, Inc.-Margaret Puckett
Address: FiR2c ArrirPy Kall Rr4 Suitp 12S CharInttA
State: NC Zip code:28277
Phone: [phone] Email: [e-mail]
Name:
Address:
State: Zip code:
Phone: Email:
Name:
Address:
State: Zip code:
Phone: Email:
If the financially responsible party is not a resident of North Carolina, give the name and address of a
North Carolina Agent:
Name:
Address:
State: Zip code:
Phone: Email:
If the financially responsible party is a partnership or other person engaging in business under an assumed
name, attach a copy of the Certificate of Assumed Name. If the financially responsible party is a
corporation, give the name and address of the registered agent.
Name:
Address:
State: Zip code:
Phone: Email: •
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WAXIIIAW EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
The above information is true and correct to the best of my knowledge and belief and was
provided by me under oath. I agree to provide corrected information should there be any
change in the information provided herein. (This form must be signed by the financially
responsible person if an individual or his attorney in fact, or if not an individual. by an
officer, director, partner, or registered agent with authority to execute instruments for the
financially responsible person)
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Name: Tri Pointe Homes Holdings, Inc.-Margaret Puckett
Address: 6325 Ardrey Kell Rd, Suite 125 Charlotte 28277
State: _NC Zip code:
Phone: [phone] Email: [e-mail]
I, l-�'l`t1G(1- 0. Sk9,1mGC1) C` , jtS , a Notary Public of e,QbaccOS
County, North Carolina, do hereby certify that mlhrqtG o,i- t2uCka personally
appeared before me this day, and being duly sworn, stated that in his presence
(signed) (acknowledged the execution of) the foregoing instrument.
Witness my hand and official seal, this the 4-1 i4 day of , 20E
(Official Seal) �� SIAM-CV-7'kt
Notary Public
My commission expires 0 1/
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