NCC223557_FRO Submitted_20221101

FINANCIAL RESPONSIBILITY10tgNERS"llp FORM
SEDIMENTATION POLLUTION CONgROL ACT
No person may initiate any land -disturbing activity on more thanl.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 N/A in the blank.)
pEr$ A.
1 • ProJect Name Cardinal Row
2• Location of land -disturbing activity: County Union
City or Township Waddington
Highway/Street Weddington Rd, Sandy Ridge�atltllde 35.00051308453298 80.71198697040676
Longitude
3• Approximate date land -disturbing activity will commence: 4/1 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc,);
Residenfal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.61
6. Amount of fee enclosed: $ $1,200
acre) is assessed without a ceiling amount (Example: a p01i cue application fee is are (rounded
r unded up to the next
�• Has an erosion and sediment control plan been filed? Yes
-- �oEnclosed %�
B. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Dame Scott Swierski
E-mail Address [e-mail]
Telephone [phone]
Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Edge 5 Realty, Inc.
Name
PO Box 78914
Current Mailing Address
Charlotte, NC 28271
City State
Zip
10. Ceed Book No. 8144
Page No. —
Part 8,
704-443-1096
Telephone au bu —Number
10700 Sike Place Suite 390
Current Street d ess
Charlotte, NC 28277
City State
0097 dip
Provide a copy of the most current deed,
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 flan is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Edge 5 Realty, Inc.
Mama
PO Box 78914
Current Mailing Address
Charlotte, NC 28271
City State Zip
[e-mail]
E-mail Address
10700 Sike Place Suite 390
Current Street Address
Charlotte, NC 28277
it State
Zip

Telephone [phone]
Fax Number
(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 State Zip
Telephone
E-mail Address
Current Street Address
City State
Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed
name, afBach 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:
Scott Swierski [e-mail]
Name of Registered Agent
PO Box 78914
Current Mailing Address
Charlotte, NC 28271
City State zip
Telephone [phone]
E-mail Address
10700 Sike Place Suite 390
Current Street Address
Charlotte, NC 28277
City State
Fax Number
Zip
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,
with the authority to
execute instruments for the Financially Responsible Person). I ragreettoeProviidet corrected information
should there be any change in the information provided herein.
Scott Swierski
Ty o1print �nj:*e
Signature
President
Title or Auth rity
Dat
a Notary Public of the County of ;
State of North Carolina, hereby certify that SCE
Personally before me this day and being duly sworn acknowledged that corm was appeared
hire, executed by
Witness my hand and notarial seal, this day of t�'� 20
Notary
My commission expires 9—l3— 6?oQ