NCC241666_FRO Submitted_20240531

\W1VAxIDIAAW EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
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: PreS6.04- Vi��aGC
Address where land disturbing activity will take place: /COO , S 1 n c I 51-•
Ua4u , n1G z.gl 7•3
Approximate date disturbing activity will commence: IJQv//kz.. 2 0'2.3
Purpose of development(residential, commercial, industrial, etc.): Gorrlmert/S
Total acreage of land to be disturbed or uncovered: ram I•S /
Amount of fee enclosed(show calculation): /606
labwap .Woo* 'too
G1se—i- i,s16 A*s-
Agent to contact shouldpp sediment control issues arise during land disturbing activity:
Name: &l'Gin >2ollac
Address: S 2.3 ROTtt rat)n Cou.r4-, di4e4H _
State: IJork G,ra(,n4 Zip code: 2-k2" 7
Phone: 9-7- 4/s f Email: br 11••r e pri .-ac Algitat 1/1c-caM
Landowner(s): /-
Name: S/c�`(bLe LG.L
Address: ld>'13 I d(.V e. i,L. (,,ta u t
State: fa r & Care PP)a Zip code: 2 S'/7 3
Phone: ?O'& 37C Email: ('a wtan Se itt e5rvta,(. c
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: <7 S S Page: 60 ere
Book: Page:
1

WAx1!11 A2 EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
Book: Page:
Book: Page:
Indicate tax map and parcel number of the property where land disturbing activity will take place
is recorded:
Tax Map: Parcel: p 6/(o SI'tO
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: 41.6.
Address: CQa( r rt4 c91ivr. its. t,Jhaw
State: )3 L Zip Code: 2 Ft'73
Phone: C}Of 1 3- 39,6 Email: ri "4'5ef Brand co set
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: 9AAla S-GA
Address: 60( (3 v,. Oi;.- RA. IJa,uc..)
State: JJ L Zip code: 2 2' 17.
Phone: my) ? 3— }.3?-4 Email: rt»..►.../sc sew,.co,,,�
2

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AXIIIAIV EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
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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)
Name: -- /I-N4 p-N S € -i 'i
Address: Got T . - OL,TVE 'ROA y W/4KH14ki
State: t4 RTI-1 CARD LI N 4 Zip code: 014 3
Phone: 04— el; - 3 6 Email: I'd rVlC(fl g FhQ Aniaed• Cow
,G' ‘ S _ pcttAi a Notary Public of__________-_
County,North Carolina, do hereby certify that 92, 1- s e 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 15 day of Sep , 20 -3,
(Official Seal) „�..,•,,,,,,,,,,,����
No ry blic rc�� S PqT
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My commission expires Q C, --- O1ARk\
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