NCC240305_FRO Submitted_20240202

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on more than1.0 acres as covered by the Act before this form and
an acceptable erosion and sedimentation control plan have been completed and approved by the Town of
Weddington. Submit this form to: 1924 Weddington Road, Weddington, NC 28104. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name A v L J `',/
2. Location of land-disturbing activity: County h11 b// City or Township ft?F'TTOtrrr
Highway/Street rae -4 "Latitude Longitude
3. Approximate date land-disturbing activity will commence: /7/` " tr ?
4. Purpose of development(residential, commercial, industrial, institutional, etc.): -ril5"4"/'
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): cp A--( ,c c.
6. Amount of fee enclosed: $ 9 7, . The application fee of$400 per acre (rounded up to the next
acre)is assessed without a ceiling amount(Example:a 10-acre application fee is$4,000).
7. Has an erosion and sediment control plan been filed? Yes ' No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
✓� eiC
Name E-mail Address G7-1-CD C f S—e.4714-z-f7/- �� �-•
Telephone Cell# 79 ' 'f3 / U 7 6 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
SSE /-k7- 7 G P
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. ° L Page No. Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
EpG r � l2 A6-7/ /-✓C_
Name E-mail Address
Current Mailing Address Current Street Address
r-7f
City State Zip City State Zip

Telephone fc>Y 7 / �! c. Fax Number
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) 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 name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided by me
under oath (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 the authority to
execute instruments for the Financially Responsible Person). I agree to provide corrected information
should there be any change in the information provided herein.
Type/or print name Title or Authority
Signature Date
I,�CL.L.J /YI. -S�k)j ifs M , a Notary Public of the County of �Yl
State of North Carolina, Hereby certify that -SC-att T. sc.J i ers}r, appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by
him.
Witness my hand and notarial seal, this 1 S day of U✓CM 10r7 20 49,3
4,,,0`;,1,414, M. sz,,,e!„,_ )4i).tc
% PN Notary
= NOrxi S
rA"Z` A&etIC �;� My commission expires �3 0�,6
iO•• a
duNTI

Avalon owners are:
Lot 1 —
Avalon L1 LLC
3109 Elmwood Dr
Monroe NC 28110
Lot 2 and lot 3 —
Edge 5 Realty Inc
POB 78914
Charlotte NC 28271
Lot 4 and lot 5 —
John Mautone
2122 Climbing Rose Ln
Matthews NC 28104

Landowner—Builder Agreement for Erosion and Sediment Control
Lot 1 Avalon
Forest Lawn Dr Matthews NC 28104
1/10/2024
POB 78914 Char NC 28271 Edge 5 Realty Inc
RE: Avalon Union Cty
To whom it may concern,
The letter gives Edge 5 Realty Inc authority to pursue plan approvals for erosion and settlement control
plans for the Avalon subdivision located on Forest Lawn Drive Matthews NC 28104. We also give
permission for Edge 5 Realty to perform construction on this property.
Please contact me at 704-443-1096 or [e-mail] with any questions
Sincerely
Scott Swierski
Member
Avalon L1 LLC

Landowner—Builder Agreement for Erosion and Sediment Control
Lot 4& 5 Avalon
Forest Lawn Dr Matthews NC 28104
1/10/2024
POB 78914 Char NC 28271 Edge 5 Realty Inc
RE:Avalon Union Cty
To whom it may concern,
The letter gives Edge 5 Realty Inc authority to pursue plan approvals for erosion and settlement control
plans for the Avalon subdivision located on Forest Lawn Drive Matthews NC 28104.We also give
permission for Edge 5 Realty to perform construction on this property.
Please contact me at 917-733-4526 or [e-mail] with any questions
Sincerely, 1
hiikt
John Mau • e