NCC232167_FRO Submitted_20230724

�.t . FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IREDELL No person may initiate any land-disturbing activity on one or more acres, '/2 acre or more inside a
COUNTY NC 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 Duckworth Retail Center
2. Location of land-disturbing activity: County Iredell City or Township Mooresville
Highway/Street Bluefield Rd. Latitude 35.595847 Longitude (-)80.869067
3. Approximate date land-disturbing activity will commence: March 2023
4. Purpose of development(residential, commercial, industrial, institutional,etc.): Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 2.0
6. Amount of fee enclosed: $ 350 . An application fee of$175.00 per acre(rounded up to the next acre)is
assessed without a ceiling amount (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$100.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ken Chesson E-mail Address [e-mail]
Telephone [phone] Cell# [phone] Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
RSD Food Market Real Estate Holding#2100, LLC
Name Telephone Fax Number
P.O. Box 2218
Current Mailing Address Current Street Address
Cornelius, NC 28031
City State Zip City State Zip
10. Deed Book No. 1559 Page No. 1087 Provide a copy of the most current deed.
Part B.
1. Person(s)or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive list of all
responsible parties on an attached sheet):
Rob Duckworth rob.duckworth©duckworths.com
Name E-mail Address
P.O. Box 2218
Current Mailing Address Current Street Address
Cornelius, NC 28031
City State Zip City State Zip
Telephone [phone] Fax Number
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2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated
North Carolina� Agent:
YZr7 (f—ar�L, Roe• 1)v614 �l"f1 /� u�'�C�..U2lk$ , CoA-,
Name E-mail Address
e0 7i.. `2' I'a / 7 E3) 51-4'T E,S r +� fe c .
Current Mailing Address Current Street Address
CU.2ry L-1 N (9 03 r0.4:NFLI Lt f
City State(, / Zip City State Zip
Telephone 7(Ju/ �/7y gd v Fax Number 7 D 9 7 r---8 /S/
(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.
/'C o+.g c2; 'Dv i:l-C wo M A r 4 a
Type or print name Title or Authority
6-.13
Signature Date
I, Mack , a Notary Public of the County of Stye\\
State of North Carolina, hereby certify that ..\,.•etk- 1=^-14-\-..,-)0r 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 2-tirk day of 50�,j#c•t , 2013
kizaji, Y1
Notary
Seal
My commission expires bteA q/2AZ3
Mark J Lighton
Notary Public
Iredell County, NC
My commission Expires June 19,2023
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