NCC240228_FRO Submitted_20240129

\�V a`C�JAtli EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
‘4A,n‘t‘.
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: Blythe Mill Townhomes
Address where land disturbing activity will take place: Blythe Mill Rd between N
Broome St and N
Providence St
Approximate date disturbing activity will commence: 8/1/2022
Purpose of development(residential, commercial,industrial, etc.): residential
Total acreage of land to be disturbed or uncovered: 18
Amount of fee enclosed(show calculation): $500 + (17 x $100) = $2,200
Agent to contact should sediment control issues arise during land disturbing activity:
Name: MTS CLT, LLC
Address: 2857 Westport Road, Charlotte
State: NC Zip code: 28208
Phone: [phone] Email: [e-mail]
Landowner(s):
Name: MTS CLT, LLC
Address: 2857 Westport Road, Charlotte
State: NC Zip code:28208
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: 8491 Page: 0806
Book: 8491 Page: 0828
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��VA1xIHW IA EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
Book: 8491 Page: 0833
Book: Page:
Indicate tax map and parcel number of the property where land disturbing activity will take place
is recorded:
Tax Map: Parcel: 06141005
Tax Map: Parcel: 06141018J
Tax Map: Parcel:
Tax Map: Parcel:
Part II
Person(s)or firm(s)who are financially responsible for the land disturbing activity:
Name: MTS CLT, LLC
Address: 2857 Westport Road, Charlotte
State: NC Zip code: 28208
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:
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 the name and address of the registered agent.
Name: J. Clark Stewart
Address: 2857 Westport Road, Charlotte
State: NC Zip code: 28208
Phone: Email:
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WAxlIIIA\W EROSION CONTROL FINANCIAL RESPONSIBILITY FORM
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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 agent with authority to execute instruments for the
financially responsible person)
Name: -- o f F PO 1.- 'T�f 3
Address: ge6.77 WeSTPo ar (CD �' 1- f7
State: Albin# COV-oe-r,v i4 Zip code: (9A - e
Phone: '70�f -3 9�i- y 4 3 Email: jVv tr--v-gt7 ECtSTwwp E- #z,Long
I, NI f4 . 01 hS a Notaiublic of �' nGo1 inCounty, NorthlCarolina, do hereby certify that <JOG F. i-O I. , vly. perSpnally
a peared before me this day, and being duly sworn, stated that in his presence J1o2 F.
tie r (signed) (acknowledged the execution of) the foregoing instrument.
Witness my hand and official s is the l3 day of 0a.P.
(Official Seal) ",,,,,„",,,,,,,,.
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My commission expires '3— I '1 , 20 _ 1- ` -
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