NCC232707_FRO Submitted_20230911

1 �AXIMAX01 EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
No person may initiate any land-disturbing activity as defined in Chapter 159 of the Town of
Waxhaw Town Code prior to completion of this form, and an applicable and acceptable erosion
and sedimentation control plan has been approved by the Development Services Department.
(Please type or print)
Part I
Name of Project: Preserve at Forest Creek (Phase 1)
Address where land disturbing activity will take place: 0 Sims Road
Waxhaw, NC 28104
Approximate date disturbing activity will commence: September 2023
Purpose of development(residential,commercial, industrial, etc.): Residential
Total acreage of land to be disturbed or uncovered: 83.26 Acres
Amount of fee enclosed (show calculation):
Agent to contact should sediment control issues arise during land disturbing activity:
Name: Dan Rossi (VP of Land Development) Pulte Home Company, LLC
Address: 11 121 Carmel Commons Blvd., Suite 450
State: North Carolina Zip code: 28226
Phone: [phone] Email: [e-mail]
Landowner(s):
Name: Fred Matrulli (VP of Land Acquisition) Pulte Home Company, LLC
Address: 11121 Carmel Commons Blvd., Suite 450
State: North Carolina Zip code: 28226
Phone: [phone] Email: [e-mail]
Name:
Address:
State: Zip code:
Phone: Email:
Indicate Book and Page where deed of the property where land disturbing activity will take place
is recorded:
Book: 7008 Page: 858
Book: Page:
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\WAX►uiA\\W EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
Book: Page:
Book: Page:
Indicate tax map and parcel number of the property where land disturbing activity will take place
is recorded:
Tax Map: Map Book J, page 843 Parcel: 05117013
Tax Map: Parcel:
Tax Map: Parcel:
Tax Map: Parcel:
Part II
Person(s) or firm(s) who are financially responsible for the land disturbing activity:
Name: Fred Matrulli (VP of Land Acquisition) Pulte Home Company, LLC
Address: 11121 Carmel Commons Blvd., Suite 450
State: North Carolina Zip code:_ 28226
Phone: [phone] Email: [e-mail]
Name:
Address:
State: Zip code:
Phone: Email:
Name:
Address:
State: Zip code:
Phone: Email:
If the financially responsible party is not a resident of North Carolina, give the name and address of a
North Carolina Agent:
Name:
Address:
State: Zip code:
Phone: Email:
lithe 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 the name and address of the registered agent.
Name:
Address:
State: Zip code:
Phone: Email:
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\WAx1utAW EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
The above information is true and correct to the best of my knowledge and belief and was
provided by me under oath. I agree to provide corrected information should there be any
change in the information provided herein. (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 ent with authority to execute instruments for the
financially responsible person) ,
Name: Fred Matrulli
Address: 11121 Carmel Commons Blvd., Suite 450
State: North Carolina Zip code: 28226
Phone: [phone] Email: Fred.MatrulliPPulteOrouo.com
El oY , a Notary Public of Me( de,,nlow'
County, North Carolina, do hereby certify that 't(( v +Milt personally
appeared before me this day, and being duly sworn, stated that in his presence
(signed) Cicknowlet. the foregoing instrument.
Witness my hand and official seal, this the I day of Se. venog
(Official Seal) L/ 1�� In4.-c-ovuduct,
//�� Notary Public
My commission expires /kt'tt U(S1 O 2O U ,``���►TE...........
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