NCC222430_FRO Submitted_20220706

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.
1. Project NameDabblinq Duck Subdivision
2. Location of land -disturbing activity: County Iredell
Highway/Street Dabbling Duck Circle Latitude 35.5705
City or Township Mooresville
Longitude-80.8962
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): _Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6 Acres
6. Amount of fee enclosed: $ 1,050 . An application fee of $175.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a 8.10-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 $100.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mark Benitez E-mail Address [e-mail]
Telephone [phone] Cell # N/A Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Peachtree Residential LLC 770-622-2522
Name
7380 McGinnis Ferry Road
Current Mailing Address
Suwanee GA 30024
City State Zip
Telephone
7380 McGinnis Ferry Road
Current Street Address
Suwanee GA
City
N/A
Fax Number
30024
State Zip
10. Deed Book No. 2883 Page No. 2449 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):
Peachtree Residential LLC [e-mail]
Name E-mail Address
7380 McGinnis Ferry Road
Current Mailing Address
Suwanee GA 30024
City State Zip
Telephone [phone]
Ir
7380 McGinnis Ferry Road
Current Street Address
Suwanee GA 30024
City State Zip
Fax Number N/A
Page 1 of 2

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:
Mark Benitez
Name
9525 BIRKDALE CROSSING DR., STE #208
Current Mailing Address
HUNTERSVILLE NC 28078
City State Zip
Telephone [phone]
NCOFFICEaPEACHTREERES.COM
E-mail Address
7380 McGINNIS FERRY RD
Current Street Address
SUWANEE GA 30024
City State Zip
Fax Number 704-997-6371
(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
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone Fax Nu
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.
M(adii 8 &—f /` 'k V f,
Type, pri t name Title or Authority
Signature V Date
I, 11 !`104V %/iYI'% '% a Notary Public of the County of
State of North Carolina, hereby certify that M612 1 1 2' 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 <JZ alb 20'r 9-
Notary
Seal
EANTHONY PITMAN
otary Public
rg Co., North Carolina
n Expires April 18, 2027
My commission expires
Page 2 of 2

9. Landowner(s) of Record (attach accompanied page to list additional owners):
KGDI LLC
Name
7380 McGinnis Ferry Road
Current Mailing Address
Suwanee GA 30024
City State Zip
770-622-2522 N/A
Telephone Fax Number
7380 McGinnis Ferry Road
Current Street Address
Suwanee GA 30024
City State Zip
10. Deed Book No. 2882 Page No. 2472 Provide a copy of the most current deed.

Peachtree Residential NC, LLC
7380 McGinnis Ferry Rd
Suwanee, GA 30024
irede Page 1 of 1
Check Total Check No. 22060063
$1,050.00 Check Date Jun 06, 2022
Vendor:
--------------------------------------------------------------------------------
irede Iredell County
Date: 06/06/2022
Check No:
22060063
--------------------------------------------------------------------------------
Invoice
--------------------------------------------------------------------------------
Date Description
Gross Amt
Adjusts
Net Amount
--------------------------------------------------------------------------------
06062022
06/06/22 erosion fmh
1050.00
0.00
1050.00
Check
--------------------------------------------------------------------------------
Subtotal ------------------»
----------- ----------
1050.00
-----------
0.00
1050.00