NCC221278_FRO Submitted_20220405

Part A.
f
FINANCIAL RESPONSIBILITY/OI VNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, 1/2 acre or more inside a
watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredell County Planning & Development, Erosion Control Section.
(Please type or print.) REu, L i. V E D
1. Project Name AMERICAN RENAISSANCE SCHOOL FEB 2 8 2022
2. Location of land -disturbing activity. County IREDELL City or Township STATESVILLE
Highway/Street S. TRADD ST Latitude39'47'4.12"N Longitude
3. Approximate date land -disturbing activity will commence: 04/01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.). EDUCATIONAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.62 ACRES
6 Amount of fee enclosed: $ 100 . An application fee of $175.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a 9-acre application fee is $1575). For projects > than 0.5 acres but no
greater than 0.99 acres in a water supply watershed, a flat fee of $135.00 is assessed.
7. Has an erosion and sediment control plan been fled? Yes No . Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name PETER ROBINSON E-mail Address [e-mail]
Telephone[phone] Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
AMERICAN RENAISSANCE SCHOOL [phone]
Name Telephone Fax Number
132 E. BROAD STREET 132 E. BROAD STREET
Current Mailing Address Current Street Address
STATESVILLE NC 28677 STATESVILLE NC 28677
City 2300 1784 State Zip City State Zip
10. Deed Book No. 2676 Page No. 832 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all
responsible parties on an attached sheet):
AMERICAN RENAISSANCE SCHOOL [e-mail]
Name E-mail Address
217 S CENTER STREET 217 S CENTER STREET
Current Mailing Address Current Street Address
STATESVILLE NC 28677 STATESVILLE NC 28677
City State Zip City State Zip
Telephone [phone] Fax Number
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2. (a) If the Financially Responsible tarty is not a resident of North Carolina, give nawe and street address of the designated
North Carolina Agent:
JIM DUFFEY [e-mail]
Name E-mail Address
217 S CENTER STREET 217 S CENTER STREET
Current Mailing Address Current Street Address
STATESVILLE NC 28677 STATESVILLE NC 28677
City State Zip City State Zip
Telephone [phone] 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:
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 by any change in the information provided herein.
JIM DUFFEY EXECUTIVE DIRECTOR
Type o . t na a Title or Authority
Sign re Date
I. N � GO k4 - ZCXK� a Notary Public of the County of _Tv--[ f
State of North Carolina, hereby certify that V t w 4_c' 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 -?? day of 1Zb-uc 20 7
Notary
Seal _
My commission expires l
NICOLE BAXLEY
Notary Public
Iredell Co., North Carolina
My Commission Expires Nov. 12, 2024
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