NCC211618_ESC Approval Submitted (2)_20210325

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any )and -disturbing activity on one or more acres, %y 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_•
2. Location of land -disturbing activity: County — r/ 1 City or Township S w {Y i/r- l��
Highway/Street 1r14_ L. Latitude 3S.731Z&v Longitude j�f
3. Approximate date land -disturbing activity will commence: 4 zp E
0
4. Purpose of development (residential, commercial, industrial, institutional; etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): Y S 4 L,
6. Amount of fee enclosed: $ . 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 $135.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes V No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name y'/S, Fay {t E-mail Address 'Co5 {l' ac-p- I16r!cJ - Co v-�
Telephone L ��� S - O rj Cell # Fax #/�
9. Landowner(s) of Record (attach accompanied page to list additional owners):
-MT5 P,Ae- F,r.,st / L G
Name --
Z 5(5 7 V"d
Current Mailing Ad ress
C "rie t tic Z �ZoZ
City State Zip
Za4 _
Telephone Fax Number
Current Street Address
City State Zip
10. Deed Book No. Z 70{p Page No. 13 E-1- t1Z I Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible
responsible parties on an attached sheet):
XTIS o.$ G
Name
I
Current Mailing Address
City y State Zip
Telephone 1-104 J/
for the land -disturbing activity (Provide a comprehensive list of all
-"0'5 it � �Sors�,c 5
E-rkdil ddress
Current Street Address
City
Fax Number
State
Zip
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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:
-A44-
Name
E-mail Address
Current Mailing Address
City State
Telephone
Current Street Address
Zip City
Fax Number
State Zip
(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 R istte d Agent E-mail Address
Current Mailing Address
City State
Telephone
Current Street Address
Zip City
Fax Number
State Zip
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
Si ure ate
Om as a Notary Public of the County of
State of North Carolina, hereby certify tha��� I its. \� � ' appeared -persoonally 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 20 V"
KAITLYN SANDS N ary IQ
eal NOtary Public
North Carolina My commission expires
4l 11
I'AecOenburg County
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