NCC221476_FRO Submitted_20220418

yy FINANCIAL RESPONSIBILITYIOWNERS-HIP FORM
..........
EROSION & SEDIMENTATION CONTROL
No person may initiate any land-disturbing activity on one or more acres, Yz acre or more inside a
watershed, as covered by the Sedimentation -Pollution- Contra( 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, Erosilork Control Section.
(Please type or print.)
Part A.
1. Project Ham
2. Location of land -disturbing activity: County &L �Fz-U_- City or Township—
Highwayf6freet /9,D Latitude 3 -7 Longitude
3. Approximate date land -disturbing activity will commence: . i , � V�-20
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (Including off - site borrow and waste areas):
6. Amount of fee enclosed: $ -T 25 . An application fee of $175.00 peracre (rounded up to the next acre) is
assessed without a calling —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 Lk No Enclosed_
S. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Nam E-mail Address S'V / -n4 v& 7 f'pdy _4'"
0 & VS
Telephon,s_Lo'Z— 7Tt�Cell # Fax
9. Landowner(s) of Record (attach accompanied page to list additional owners):
.4, 1,04
Na 7t,
Current Mailing Address
&-g_v.-rg.fW -d-L
City State Zip
Telephone Fax Number
Current Street Address
city stata Zip
10. Deed Book No. lov&_Page w. /3M Provide a copy of the most current deed.
Part B.
1. Person(s) pr firm(s) who are finincially responsible for the land -disturbing activity (Prkde a comprehensive list of all
responsible parties on an attached sheet):
W
Aklz�sfl I � 5�Al
Name E-mail Address
V// 14,04AA-�-EkV MAM
Current Mailing Address Current Street Address
City State zip City State Zip
Telephone Fax Number
Page 1 of 2

(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street addrest, of the designated
North Carolina Agent:
Name
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip city
Telephone Fax Number
Slate 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 E-mail Address
Current Mailing Address Current Street Address
city state Zip city state Z71P
Telephone Fax Number
Theabove 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 info I rmation should there by any change in the information provided herein.
I,e
'rype or print name ne Title or Authority
Signature Date
I, a Notary Public of the County of I nekl I
State of North Carolina, hereby certify that SYMPI - --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 _ffdaiy of 2ol-O
TtRESA MAZER Notary
6dtary Public, North Carolina
Mecklenburg County My commission expires —
MY C m 11 Sion Expires
W
Page 2 of 2