NCC223501_FRO Submitted_20221031

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
Waddington. Submit this form to: 1924 Waddington Road, Waddington, NC 28104. (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.
1. Project Name Weddington Glen Subdivision - Lot Grading
2. Location of land -disturbing activity: County Union City or Township. Weddington
Weddington-
Highway/Street Matthews Road Latitude 35.032313 Longitude -80.743640
3. Approximate date land -disturbing activity will commence: _Sept. 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): single family residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.50
6. Amount of fee enclosed: $ 3,600.00 . 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:
Name Robert J. Kardos E-mail Address—[e-mail]
Telephone [phone] Cell # 704-582-3989 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Beechwood Weddington, LLC 704-582-3989
Name Telephone Fax Number
7621 Little Ave., Ste. 111 7621 Little Ave., Ste. 111
Current Mailing Address Current Street Address
Charlotte NC 28226 Charlotte NC 28226
City State Zip City State Zip
10. Deed Book No. 08342 Page No. 0857-0882 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.
Beechwood Weddington, LLC [e-mail]
Name E-mail Address
7621 Little Ave., Ste. 111 7621 Little Ave., Ste. 111
Current Mailing Address Current Street Address
Charlotte NC 28226 Charlotte NC 28226
City State Zip City State Zip

Telephone [phone]
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
Current Mailing Address
City
Telephone.
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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
Current Mailing Address
City
Telephone,
State Zip
E-mail Address
Current Street Address
City State Zip
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.
ti
Type or pri na e Title or Authority
Signature Date
-- — -------- --- ---------- A -------------------------- — ----------------- _­ ------------------------- - ---- ---- — --------
I, L 4 , a Notary Public of the County of H P C �( � C _
State of North Carolina, hereby certify that ' YC' 7 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 . l S day of � , 20
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