NCC215461_FRO Submitted_20211006

Part A.
1. Project Name
FINANCIAL RESPONSIBILITY/OWNERSHIP 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.)
gP1"C-1_C)WW H. 6"�
2. Location of land -disturbing activity: CountyJ-06MLL- City or Township
VJD& V 1L
Highway/Street IV U`J N\ Latitude 3 I JJ I t'{ Longitude _ 20w_)7130
3. Approximate date land -disturbing activity will commence: , 1) `i __
4. Purpose of development (residential, commercial, industrial, institutional,
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 51109
6. Amount of fee enclosed: $ ) V 50 . 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_ No Enclosed
8. Person
jto,"�contact should erosion and sediment control issues arise during land -disturbing activity:
t
Name { " ICI -IN -EL v` or P_ E-mail Address es ��Tr (� �) 3 ��� b •7
Telephone '?Dq t4 33 99 / Cell # �, 1 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Telephone
Fax Number
Fj�x (� S l� sy���uN� 3 ac�wu., ��I �7 Ali M
P�-4!C
Current Mailing Address 'I Current Street Address ;Ile/J _711-
City
State Zip
City
State
10. Deed Book No. a (10 3 Page No. Provide a copy of the most current deed.
Part B.
ME
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)
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Name
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Current Mailing Address
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City State Zip
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E-mail Address
Current Street Address
A1M9,ts w/&- Ax- aW-/]
City State Zip
Telephone 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:
Name
Current Mailing Address
E-mail 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 Ti�7z';Xl
Signature Date
1, , a Notary Public of the County of _
State of North Carolina, hereby certify that
and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this day of 20
Seal
Notary
My commission expires
appeared personally before me this day
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