NCC241915_FRO Submitted_20240628

WA Xun AW '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:The Shops at Prescot Village
7521 Prescot Glen Pkwy
Address where land disturbing activity will take place:
Waxhaw,NC 28173
Approximate date disturbing activity will commence: Spring 2024
Purpose of development(residential,commercial,industrial,etc.): Commercial
Total acreage of land to be disturbed or uncovered: 16
Amount of fee enclosed(show calculation): $500(first acre)+(15 x$100)=
$2,000+$200(10%tech fee)=$2,200
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 100,East Syracuse
State: NY Zip code:13057
Phone: [phone] Email:[e-mail]
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:
1

WAXWIAW 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: Q6165003P
Tax Map: Parcel: 06165003A
Tax Map:_ Parcel:
Tax Map: Parcel:
Part II
Person(s)or finn(s)who are financially responsible for the land disturbing activity:
Name: Widewaters Prescot Onwnership,LLC
Address: 5845 Widewaters Parkway,Suite 100,East Syracuse
State: NY 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: 160 Mine Lake Ct,Suite 200.Raleigh
State: NC Tin rnrle•27615
•
Phone: [phone] Email: [e-mail]
2

yrIAW 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) �/fj�
Name: JDizi9 2 u 1"� . /"l/Glll�f e>�
\'•/.....,-----
Address: S' y l AJit �' i f7J .'fit- C),'11
State: /Y 7 N Zip code: �/
315-445-2424 "'scuderi lewaters.corn
Phone: Ematl.l
I. C21ochet le ttrim . a Notary Public of 0nondaszy0.
County, Newyork ., do hereby certify that ,Somme.ph SGud.eri personally
appeared before me this day, and being duly sworn, stated that in his presence Josep1--1
5c.ud..e r=i (signed) (acknowledged the execution of)the foregoing instrument.
Witness my hand and official seal, this the 2-9' day of Move mb2r, 20 23.
(Official Seal)
Notary Public
My commission expires 003,r,1c> ROCHELLE DRUM
e.r `7 2027. Notaryry Public.State of New York
Ouafrfied in Onondaga County
No.010R6398935
CORttnhision Expires:10/07/ .7
3

ORIGIN ID:SYRA [phone] SHIP DATE:30NOV23
ROCHELLE DRUM ACTWGT:0.50 LB
THE WIDEWATERS GROUP CAD:1118307921INET4535
5845 WIDEWATERS PARKWAY
SUITE 100
EAST SYRACUSE,NY 13057 BILL SENDER
UNITED STATES US
TO BRIAN LONG
THE WIDEWATERS GROUP, INC. w
10800 SIKES PLACE, SUITE 225
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CHARLOTTE NC 28277 c, '° ' > - "
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