NCC220793_FRO Submitted_20220217

Part A.
1.
2.
3.
4.
5.
FINANCIAL RESPONSIBILITYIOWNERSHIP 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.)
Bungalows on North Kelly
Project Name
Location of land -disturbing activity: County I redel I City or Township Statesville
N. Kelly St 35.795214-80.899024
HighwaylStteet Latitude Longitude
Approximate date land -disturbing activity wil I commence: 9/2/21
Purpose of development (residential, commercial, industrial, institutional, etc.): _Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.5 acres (change of entity)
6. Amount of fee enclosed: $. 0 . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Michael Wetter E-mail Address [e-mail]
Telephone _ Cell 4 .._704-433-9947 Fax 4
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Eight Dot Five Enterprises LLC 704-208-4251
..,,� Telephone
PO Box 3965
Current Mailing Address
Mooresville NC
Stat
10. Deed Book No. _ Page
Part B.
Fax Number
Current Street Address
28117
Zip City Zip
Provide a copy of the most current deed.
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):
Helmsman Homes LLC
Name
PO Box 3965
Current Mailing Address
Mooresville NC 28117
City State Zip
Telephone [phone]
704-208-4251
E-mail Address
Current Street Address
City State
Fax Number
Zip
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2. (a) If the Financially Responsible Party . not a resident of North Carolina, give name and street address of the designated
North Carolina Agent:
Name
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State
Fax Number
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 Fi cially Responsible Party is a Corporation, give name and street
address of the Rvistered Agen) ]
�*+CA•Qsca—
tered Agent E-mail Address
Current ailing Address CurreqpjStreet Address
l /--?---y7
ity State Zip City State Zip
Telephone d6 ` �l�ird 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 farm
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 rrected information should there by any change in the info ation provided herein.
Type or print name Title or Au on
l
Signat
hh
I, �,�t w� 4y� ], eK , a Notary Public of the County of
I ,,,,aGC, C
State of North Carolina, hereby certify that'eared 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 Z::)0 " f
Notary 9
Seal /
JENNA DUBQIS �FA'
Notary Public, North Nfbliha
Mecklenburg COUrtty
My iss 6n -xpi mmr 5
My commission expires �� W r
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