NCC222365_FRO Submitted_20220714

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
Im. 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 Name Shinn Village
2. Location of land -disturbing activity: County Iredell City or Township Mooresville
Highway/Street Shinnville Road Latitude 35.648824 Longitude-80.807232
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 60.33 AC
6. Amount of fee enclosed: $ 10,675 . 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 fiat fee of $135.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed,V
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David Hughes E-mail Address dhu hes nest Communities.com
Telephone Cell # 704-787-5622 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Shinnville Farms Development Partners, LLC
Name
PO Box 3965
Current Mailing Address
Mooresville NC 28117
City State Zip
[phone]
Telephone Fax Number
236 Raceway Dr, Suite 7
Current Street Address
fid000res_Ale „ NC 28117
city state Zip
10. Deed Book No. 2884 Page No. 2190 - 2194 Provide a copy of the most current deed.
Part B.
1. Person(s) or frrm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all
responsible parties on an attached sheet):
Shinnville Farms Development Partners, LLC dhughes@nest Communities.com
Name E-mail Address
PO Box 3965
Current Mailing Address
Mooresville NC 28117
city State Zip
Telephone [phone]
236 Racewav Dr. Suite 7
Current Street Address
Mooresville NC 28117
City State Zip
Fax Number
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(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated
North Caroline Agent
Name E-mail Address
Current Mailing Address Current Street Address
City State Zap Cily stela Zip
Telephone Fax Number
(b) If the Financially Responsible Party Is a Partnership or other person engaging in business under an assumed name, aMch
a copy of the CortMosile of Assumed Name. If the Financlatly Responsible Party is a Corporation, give name and street
address of the Registered Agent
Name of Registered Dent E-mall Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
The above Information is true and nomad to the best of my knowledge and belief and wee provided by me under oath (This form
must be signed by the Financially Responsible Person If an individual or his attorney4n-fad or p not an individual, by an officer.
dlraclor, parbter, or registered agent with the audwty to execute instruments for the Financially Responsible Person). I agree to
provide corrected information should there by any change in the information provided herein.
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Signature Or DOD
a Notary P,j
Public off tCounty Couof WO O
State of North Carolina, hereby certify that iG/4GVI//�W he,-s appeared personally before me this day
and being duly sworn acknowledged that the above form waswiscUted by him.
VVibness my hand and notarial seal, this day of ! / 24or
Notary
�Rbta D�
NOTARY PUBLIC
1r8&II County, NO
My Commission Expires June 22, 2022
My commission expires t./z4OOe 4?-7- &IZ7 -
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