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HomeMy WebLinkAboutNCC232980_FRO Submitted_20231006 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM i 141\ ;<< EROSION & SEDIMENTATION CONTROL DELNo person may initiate any land-disturbing activity on one or more acres, % acre or more Inside a watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land '4. 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 Thunder Rd Lots 1.2/13/14 City Mooresville 2. Location of land-disturbing activity: County ity or Township Highway/Street Thunder Rd Latitude Longitude 3. Approximate date land-disturbing activity will commence: August 15, 2023 Commercial 4. Purpose of development(residential,commercial,Industrial,Institutional,etc.): 5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 5.52 6. Amount of fee enclosed:$ 1050 . 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 flied? Yes x No Enclosed 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Butch Bouwens E-mail Address butch@empirebuildgroup.com Telephone 7 0 4-3 6 3-8 7 0 7 Cell# Fax# 9. Landowner(s)of Record(attach accompanied page to list additional owners): LCB PROPERTIES LLC 704-363-8707 Name Telephone Fax Number 765 McKendree Rd Current Mailing Address Current Street Address Mooresville NC 28117 City State Zip City State Zip 10. Deed Book No. 18 67 Page No. 17 5 5 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): LCB PROPERTIES LLC butch@empirebuildgroup.com Name E-mail Address 765 McKendree Rd 765 McKendree Rd Current Mailing Address Current Street Address Mooresville NC 28117 Mooresville NC 28117 City State Zip City State Zip Telephone_ 704-363-8707 Fax Number 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 or print name .�+ Title or Authority izew ,SouuJert1.1 ..3r !/3i/z Signature Date I, (i..CA nd c_e )Q fl heal ,a Notary Public of the County of TrQde.\ State of North Carolina, hereby certify that hCh Al. eIA 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 3\ day of Sid ly ,20 33 C ede)- glithkkki Notary Seal �����llllllllll,,,,� My commission expires \ \� to 3 NFL', PUR) • i DELL G