NCC222498_FRO Submitted_20220712

RECEIVED
APR 2 5 2022
FINANCIAL RESPONSIBILITY/OWNERSHIP 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 this form and an acceptable erosion
and sedimentation control plan have been submitted and approved by the Iredell County Development Services, Planning Division -
Erosion Control Section. (Please type or print.)
Part A.
1. Project Name Randy Marion - Subaru
2. Location of land -disturbing activity: County Iredell City or Township Mooresville
Highway/Street W Plaza Dr Latitude 35035'aQ_6_ Longitude 80051'4.45"
3. Approximate date land -disturbing activity will commence: June 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): parking lot
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.4 acres
6. Amount of fee enclosed: $ 350 . 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 .5 acre but a 1.0 acre
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 x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name P. Scott Bell, PE
Telephone [phone] Cell #
E-mail Address [e-mail]
704-770-0143 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners).
6K Properties, LLC
Name
PO Box 1559
Current Mailing Address
704-659-7037
Telephone
215 West Plaza Drive
Current Street Address
704-230-1302
Fax Number
Mooresville, NC 28115 Mooresville, NC 28117
City State Zip City State Zip
10. Deed Book No. 2839 Page No. 553 Provide a copy of the most current deed.
Part B. 2467 2460
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):
6K Properties
Name
PO Box 1559
Current Mailing Address
Mooresville, NC 28115
City State Zip
Telephone [phone]
ebroach@randymarion _com
E-mail Address
215 West Plaza Drive
Current Street Address
Mooresville, NC 28117
City state Zip
Fax Number 704-230-1302
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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;
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Telephone Fax Number.
State 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 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 in the information provided herein.
Randall L. Marion Member
T int name
�.
Signature
Title or Authority
4/20/2022
Date
a Notary Public of the County of _)adel l
State of North Carolina, herrbby certify that r[1 LrM 11 L. - ,] ill, 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 215t day of .20
J'Noat
Seal iis...... �Q
c3° tr My commission expire
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