NCC241920_FRO Submitted_20240627

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WAu r. 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: The Shops at Prescot Village-Offsite ESC
Address where land disturbing activity will take place: 7521 Prescot Glen Pkwy
Waxhaw, NC 28173
Approximate date disturbing activity will commence: Summer 2024
Purpose of development(residential,commercial,industrial, etc.): Commercial
Total acreage of land to be disturbed or uncovered: 13.04
Amount of fee enclosed(show calculation): $500 (first acre) + (13 x$100) =
$1,800+$180(10%tech fee) =
$1,980
Agent to contact should sediment control issues arise during land disturbing activity:
Name: Brian Long
Address: 10800 Sikes Place, Suite 225. Charlotte
State: NC Zip code:28277
Phone: [phone] Email: [e-mail]
Landowner(s):
Name: Widewaters Prescot Ownership, LLC
Address: 5845 Widewaters Pkwy, Suite 110, East Syracuse
State: NY Zip code: 13057
Phone: [phone] Email: blong cc widewaters.com
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: 8717 Page: 0698
Book: Page:
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�IVAXIIIIAIV 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: Parcel: 06165003P
Tax Map: Parcel: 06165003A
Tax Map: Parcel:
Tax Map: Parcel:
Part II
Person(s) or firm(s)who are financially responsible for the land disturbing activity:
Name: Widewaters Prescot Ownership, LLC
Address: 5845 Widewaters Pkwy, Suite 100, East Syracuse
State: New York Zip code: 13057
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: CT Corporation System
Address: 2626 Glenwood Ave, Suite 500, Raleigh
State: NC Zip code:27608
Phone: [phone] Email: [e-mail]
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\OVA Xi1-11 AAW 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)
Name: Joseph R. Scuderi, Manager
Address: 5845 Widewaters Pkwy, Suite 1 , East Syracuse
State: NY Zip code: 13057
Phone: [phone] Email: [e-mail]
I, iocheile , a Notary Public of 0rlcndo gc
County, lSev,> York. , do hereby certify that JOI Qph R. S' cude.ri personally
appeared before me this day, and being duly sworn, stated that in his presence J 0sep`c1 R,
Sc.o.d.er\ (signed) (acknowledged the execution of)the foregoing instrument.
Witness my hand and official seal, this the (?) ' day of M 0.y ,20 ZLl
(Official Seal)
Notary Public
ROCHELLE DRUM
Notary Public,State of New York
My commission expires Oc.-ob e.r 7 .20 21. Qualified in Onondaga County
No.01DR639S935
Commission Expires: 10/07/L1
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ORIGIN ID:SYRA [phone] SHIP DATE:13MAY24
ROCHELLE DRUM ACTWGT:0.50 LB
THE WIDEWATERS GROUP CAD:111830792/INET4535
5845 WIDEWATERS PARKWAY
SUITE 100
EAST SYRACUSE,NY 13057 BILL SENDER
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TO BRIAN LNG
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