NCC220202_FRO Submitted_20220111

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/or fax information
unavailable, place NIA in the blank.)
Part A.
I. Project Name Waxhaw Downtown. Park
2. Location of land -disturbing activity: County. Union City or Township Waxhaw
Highway/Street 301 Givens Street Latitude 80.7449250 W Longitude 34.9220540 N
3. Approximate date land -disturbing activity will commence: October 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreation
7.23 <W
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): Acres
6. Amount of fee enclosed: $ $520 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dena Sabinske E-mail Address [e-mail]
Telephone [phone] ext. 278 Cell ## 704-290-6552 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Waxhaw, NC 704-843-2195 ext. 254
Name Telephone Fax Number
KW Kw
i , 60 �i - _ _ • P.O. Box 617 401 Givens S fye . 1150 N Broome St
Current Mailing Address Current Street Address
Waxhaw NC 28173 Waxhaw NC 28173
City State Zip City State Zip
10. Deed Book No. 5815 Page No. 200 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.
Town of Waxhaw, NC
Name
Kw
11BreenreStfee> P.O. Box 617
Current Mailing Address
Waxhaw NC 28173
City State Zip
[e-mail]
waxhaw.com
E-mail Address
1150 N. Broome Street'P.0 `Bax 6 -�—
Current Street Address
Waxhaw NC 28173
City State Zip

Telephone [phone] ext. 254 Fax Number 704-843-2196
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:
NIA
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:
NIA
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.
Jeff Wells Town Manager
Type J�i me Title or Authorit
Sig0# Date
DS u1eV , a Notary Public of the County of Un1ff\
State of North Carolina, hereby certify that UJOI is 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
)5_fh day of Tul Lj , 20_aL_
uj�/-
Not4-
My commission expires' ju lb