HomeMy WebLinkAboutNCC230450_FRO Submitted_20230216FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, '/z 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)
Part A.
1. Project Name
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2. Location of land -disturbing activity: County 1 rPj 11 City or Township moorie" V'I 11
Highway/Street ( LN'A(F f?_, Latitude Longitude
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): 6T47-/AV
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3 ' D O
6. Amount of fee enclosed: $ '5-a's-• cTo . An application fee of $175.00 per acre (rounded up to the next acre) is
assessed without a ceiling arrtount (Example: a 8.10-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 $100.00 is assessed.
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 GIB 000-5I�Af1' E-mail Address r�bloonstae @ arhome-s.Com
n
Telephone Cell # 10q - 00 ` V'7p7 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
N Telephone
Current Mailing Addre �.J Current Street Address
Fax Number
City StXel I Zip City State Zip
10. Deed Book No. : U— Page No. Provide a copy of the most current deed.
Part B.
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):
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Name E-mail Address
ISlo37 r��t�li►i�. �it1'6r
Current Mailing Address
Urvie! IL)& 06 20031
City State Zip
Telephone 70 q - �3q - 3010
Current Street Address
Corn! iys tic
City State Zip
Fax Number
Page 1 of 2
Davidson Pond Landowners:
Lot 34
Christopher A Davy
Christa L Davy
16522 Redding Park Lane
Cornelius NC 28031
Deed Book 2943 — Pages: 1153-1154
Lot 39
Edward Dean
Tomeisha Dean
2286 Eversham Dr NW
Concord NC 28027
Deed Book 2939 — Pages: 72-73
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
E-mail Address
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Telephone
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.
Type A print name Title or A ority
Signature Date
a Notary Public of the County of A u
State of North Carolina, hereby certify that A I I 1,6m d S appeared personally before me this day
and being duly sworn acknowledged that the above form, Iwas executed by him. V
Witness my hand and notarial seal, this day of 20 23
Notary
Seal ��Anneeeeeo
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My commission expires V '15y`' �✓
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