NCC215730_FRO Submitted_20211015

FINANCIAL 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.
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Project Name
Location of land -disturbing activity: County tredell City or Township Mooresville
Highway/Street_Waterlynn Road Latitude 35,558 Longitude-80.850
Approximate date land -disturbing activity will commence: 10/18/2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Mixed use
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5 ac — revised area
Amount of fee enclosed: $ 250 . An application fee of $176.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a 9-acre application fee is $1575). For projects a than 0.5 acres but no greater
than 0.99 acres in a water supply watershed, a flat fee of $135.00 is assessed.
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chris LaMack E-mail Address clamack(&elevation-re.com
Telephone [phone] Cell #
Landowner(s) of Record (attach accompanied page to list additional owners):
Granger Village Holdings, LLC
Name
_9541 Julian Clark Ave., Suite 101
Current Mailing Address
Huntersville NC 28078
City State Zip
Fax #
704-363-6109
Telephone Fax Number
9541 Julian Clark Ave. Suite 101
Current Street Address
Huntersville NC 28078
City State Zip
10. Deed Book No. 2754 Page No. 1174 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):
Granger Villa e Holdings, LLC
Name
9541 Julian Clark Ave., Suite 101
Current Mailing Address
clamack = elevation-re.com
E-mail Address
9541 Julian ClarkAve., Suite 101
Current Street Address
le NC 28078 Huntersville
City State Zip City
Telephone [phone] Fax Number
State
28078
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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:
ame
E-mail Address
Current Mailing Address Current Street Address
City State Zip ity State Zip
Telephone
ax 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 rin the information provided herein.
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Type rint name Title or Authority
nature Date
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I ,_ L4151 t , a Notary Public of the County of A vCJ(- If,
State of North Carolina, hereby certify that ri 5 La, )M Lx C k _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 ' day of 0 L4-0 be 20 �
Notary
eal OTAL!L h WUi.F '9 Q
Maccidenbu PAC My commission expires
North Carolino�
Commission EYVrea Feb 2},�
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