NCC222719_FRO Submitted_20220729

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 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 Nest Homes Salem Springs
2. Location of land -disturbing activity: County (reel .II City or Township Statesville
Highway/Street Salem Creek Dr Latitude35.795111 Longitude-80.782164
3. Approximate date land -disturbing activity will commence: 4-11-22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
61 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 22'
6.
7.
8.
9.
Amount of fee enclosed: $ . 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.
Has an erosion and sediment control plan been filed? YesX No Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Allen Johnston E-mail Address ajohnstonahelmsmanhomes.com
Telephone
Cell # 704-326-6736 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Salem Springs Land Development, LLC 980-500-1245
Name Telephone
PO BOX 3965
Current Mailing Address
Mooresville, NC 28117
Current Street Address
City State Zip City
Fax Number
State Zip
10. Deed Book No. 2846 Page No. 830 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):
Helmsman Homes, LLC [e-mail]
Name E-mail Address
116 Gasoline Alley, Suite 105
Current Mailing Address
Mooresville NC 28117
City State Zip
Telephone [phone]
Current Street Address
City State Zip
Fax Number
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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 State Zip
Telephone 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 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 gwrectedd�information should there by any change in the information provided herein.
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Signature
Title or Authority
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Date
I, ( AL"Dad G � a�N"otary Public of the County of 360, 0-y. � _
State of North Carolina, hereby certify that �11 0� 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 ik� day of 20010,
Notary V
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My commission expires Q�%� /w2A=
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