HomeMy WebLinkAboutNCC215556_FRO Submitted_20211007FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, '/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.)
Part A.
1. Project Name
2. Location of land -disturbing activity: County f UeAe-.1, City or Township T (yi— -i'Y) C',_
Highway/Street ern && Vc�Latitude 85 , GPjQ.`-( Longitude - g0' G
3. Approximate date land -disturbing activity will commence: 0C t('1 "' C f c-U� I
4. Purpose of development (residential, commercial, industrial, institutional, etc.): 1'1�S t�e �{ t c 1
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ MO . 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? Yeses_ No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name C f%' f CO(fo E-mail Address '•:':C-&(fC) De _ ( C%-00'(`n
Telephone 76 4 - (o aV - 7 3 :�Cell # t Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
girth a-AL1 LLC.
Name
-7�i (-r en
Current Mailing Address
City State Zip
10. Deed Book No. Page No.._ c1-
Part B.
Telephone
Current Street Address
City
Fax Number
State
Provide a copy of the most current deed.
Zip
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):
Gee < "gLQ I1Q D_ e ii01+cam)
Name
Mas A((Ow(_,AQ e Stocd
Current Mailing Address
C h pa (n4( M (_ aga-7-
City State Zip
Telephone -7 U'4 - (r a0 -7 3 _
Q,C acro It e D _-6r+('r'. C0
E-mail Address
Current Street Address
City State Zip
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:
C-T Coy -
Name
i fl-� 0 (1) C -t-CA v ae\ o C O CV\
E-mail Address
16SZEa .i eke S+,r Ce t
Current Mailing Address
City State Zip
Current Street Address
City
Telephone f q - 6 �L - -I f . 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 Registered Agent
Current Mailing Address
city
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
lT�ot X.,1 ale f-111a4ase-1'
Type or p t name Title or Authority
Signatur Date
I, R(Lckd May- yN l-liLllLS , a Notary Public of the County of Ga%-btvx
State of North Carolina, hereby certify that AeoMt II,4_1tjW Ca.IVVO i _ appeared personally before me this day
and being duly sworn acknowledged that the abov . orm was execu ed by him.
Witness my hand and notarial seal, this 2A day of St M1X k' _, 20
Seal
Rachel Martin Hayes
NOTARY PUBLIC
Gaston County
North Carolina
My Commission Expires May 27, 2025
��Q {M.Cx.L� .j4yjow
Notary My commission expires M 1-1 2AZ5
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