NCC221782_FRO Submitted_20220510

F[14,..4CIAL RESPONSIBILITYIOW..cRSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, '/ 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 sedimtM
IFFsubmitted
and approved by the Iredell County Planning & Development,
(Please type or print.)
Part A.
1, Project Name OgY1(tson OonJ
MAR 17 2022
2. Location of land -disturbing activity. County_hl Q{r City or Township 14conesvi*
Highway/Street t�0n & i5liude 3T 51$ 771Z Longitude 90- $�' 23I
1 O
3. Approximate date land -disturbing activity/ will commence: MaQ15, 1o2 2
J 4. Purpose of development (residential, commercial, industrial, institutional, etc.): �051 do V?�, �/I
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 9 C110 rQ
6. Amount of fee enclosed: $ 1 76-oy . 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 to contact should erosion and sediment control issues arise during land -disturbing activity:
Name L454or De L",r) E-mail Address L.asky-J1 A0 1doa8 • gpD
Telephone Cell # �7$61s9-� 6213 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
D90YV OL Loon (796)b26-ob06
Name Telephone
Fax Number
2670 00/Woo&i P) 2470&rwoodit PI
Current Mailing Address Current Street Address
mask48 FL 3o3s h6reshgA FL 331636-
City -7 State Zipe/ City State Zip
10. Deed Book No. Page W. 17fD 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}: _ I
J.t�r DV L"e) �rcV�o(d .G01Y'f
Name E-mail Address
,2670 Ounwoo cb e, P1
Current Mailin Address
16 m Qs d&9 F-L 3303'5-
City State Zip
Telephone f716 J099- 627-
2(m Oanccio",a P�
Current Street Address
lrilrs�Q�� fL 33035
City State Zip
Fax Number

2. (a) If the Financially Responsible f y is not a resident of North Carolina, give nai and street address of the designated
North] OW
Agent -- II.. �bl!'IQ Jq n Q Z 14.EEq01OM61WWQrMd. coo
Name E-mail Ad res
15-4 140n�'Y a 1ss_004rr 4ao U[?_P )
Current Mailing AddresF Current Street Address
N oofatvl 14 �� 2$! 1 �" q oOfQS lrl(e
City Stater Zip City State Zip
Telephone��0 �� 1 671 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
Telephone Fax Number
State Zip
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 attomey-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.
Lela r 0A Lao n
Ty prl ame Title or Authority
a18IZaa2
Signature Date
1, M rl 5 a is VZ-eCn , a Notary Public of the County of f l t G�� t ` �Q
�l c snl 9 5 -kr 0C- (if tt1
State of PleWrt'ar+xtrla, ereby certify that. OnGC appeared personally before me this day
and being duly swam acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this day of .20 22
atary
Seal B 1'Z— 2 CJ ZS
My commission expires
E
y Public Stateof Florida
isol Sizemore
CommkulonH 184735p.Il11212025