NCC243433_FRO Submitted_20241126

* 11117.1614112.\4::::\ *
- WA Xa111 A\W
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by Chapter 9, Section 9.2
of the Town of Waxhaw Land Development Code. No sedimentation and erosion control plan will be reviewed
without submission of the completed form, an associated erosion and sedimentation plan and the appropriate
fee. Submit the completed form, associated erosion and sedimentation plan to the Town of Waxhaw
Engineering Department, Attn: Sedimentation and Erosion Control Inspector, along with the appropriate fee.
(Please type or print and, if the question is not applicable or the e-mail address or phone number is unavailable,
place N/A in the blank.)
Part A.
1. Project Name Primrose School Day Care
2. Location of land-disturbing activity: County__. Union City or Township Waxhaw
Highway/Street Cuthbertson Latitude(decimaidegrees)34.956821 Longitude(decimaidegrees)-80:754935
3. Approximate date land-disturbing activity will commence: January 2025
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.19 AC
6. Amount of fee enclosed: $ 660.00 . The application fee of $500.00 for first acre and
$100.00 for each additional acre, or part thereof (rounded up to the next acre) plus a 10% Technology
Fee is assessed without a ceiling amount. Checks are to be made out to the Town of Waxhaw, with
Sedimentation and Erosion Control Fee shown on the reference line. Sedimentation and Erosion Control
fees are to be paid separately from site plan review fees.
7. Has an erosion and sediment control plan been filed? Yes E Enclosed X No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Matt Taylor E-mail Address [e-mail] TT
614+
Phone: Office# 901-9015 Mobile# /I -Obi -0i0V5
9. Landowner(s)of Record (attach accompanied page to list additional owners):
2421 Cuthbertson, LLC 704-303-5364
Name Phone: Office# Mobile#
A
X
Ill , (i! Hours:Monday-Friday P.704.843.2195 www.waxhaw.comW P.O.Box 6
® 8:00 a.m.—5:00 p.m. F.704.843.2195 1150 North Broome St
Est.1889 Waxhaw.NC 28173

6400 Bamington Rd
Current Mailing Address Current Street Address
Charlotte NC 28226
City State Zip City State Zip
10. Deed Book No. 7269 Page No. 789 Provide a copy of the most current deed.
Part B.
1. Company(ies) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on accompanied page.)If the company is a sole proprietorship
or if the landowner(s)is an individual(s),the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Primrose School Franchising Company LLC [e-mail]
Company Name E-mail Address
3200 Windy Hill Road,SE
Current Mailing Address Current Street Address
Atlanta GA 30101
City State Zip City State Zip
Phone: Office it 615-901-9015 Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry,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
Phone: Office# Mobile#
Name of Individual to Contact (if Registered Agent is a company)

(b) If the Financially Responsible Party is not a resident of North Carolina, give name and
street address of the designated North Carolina agent who is registered on the NC
Secretary of State business registry:
CT Corporation System [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct,Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Phone: Office# 617-901-9015 Mobile#
Steve Clemente
Name of Individual to Contact (if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name,give name under
which the company is Doing Business As_ If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
ITI� Ut pr?Jde41 r-,_ t 1ou
e or pri name Title or Authority
0/ // I?
igna re Date
X I, S Outil � , a Notary Public of the County of _Orl/ 0 0
State of North Carolina, hereby certify that Ma L4hC¼U 1(1 /Or appeared personally
before me this day and being duly sworn acknowledged that the abov€form was executed by him/her.
Witness my hand and notarial seal, this J day of_ ___.^, 20

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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No- Page No. Provide a copy of the most current deed.

Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#

Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#