NCC222823_FRO Submitted_20220811

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION EBI T TICONTROL
No person may initiate any land -disturbing activity on one or more acres, % acre or more inside a'
watersheds as covered by the Sedimentation Pollution Control Act and the tredeil County Land
Development Code, before an acceptable erosion and sedi "'"'f ri: "suP r»itted
and approved by the tredeti County Planning & Development
4+
(Please type or print)
Part A. JUN 8 2022
1. Project' Name Timber Ridge Lot 11
2, Location of land -disturbing actiutty„ County Iredell sty or Township Mooresville
Highway/Street 125 N Commercial Drive Latitude 35.559737 Longitude-80.820112
I Approximate date land -disturbing activity will commence: 7i15/22
4. Purpose of development`(resideniiai commercial, industrial, institutional, etc.)! Industrial
5. Total acreage disturbed or uncovered (Including off -site barrow and waste areas)- 2.8 PC
6, Amount of fee enclosed: $ 52J An apptication fee of $175 00 per acne (rounded ;up to the next acre) is
assessed without a ceiling amount (Example: a;8.10-acre application fee is $1575)i 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? YesNo Enclosed x
8. Person to contact should erosion and sediment control issues arise during land4i`sturbing activity, -,:
Name Richard Skaff E-mail Address [e-mail]
Telephone [phone] Cell # Fax# [phone]
9W Landowner(s) of Record (attach accompanied page to list additional' owners)„
S&S Family Limited Partnership 704-663-1563 704-663-7207
Name ' Telephone Fax Number
PO Box 3216 PO Box 3216
CurrentiMalling Address Current Street Address
Mooresville; NC.", Mooresville NC
City State Zip City State Zip
10, Deed Book No. 1309 Page No. 608-609 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):
S&S Family Limited Partnership I [e-mail]
Name E-mail Address
PO Box 3216 PO Box 321
Current Mailing Address` Current Street Address
Mooresville NC Mooresville NC MIT
City State Zip City State Zip
Telephone [phone] Fax `Number 704-663-7207
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2, (a) If the Financially Responsible Party"is not a resident North Carolina, give name and street address of the designated
North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
city Stat Zip City State Zip
Telephone / Fax Number
(b) If the Fin racially Responsible Party is a Partnership or other rson engaging in business under an assum ame, attach
a copy r he Certificate of Assumed Name. If the Fina sally Responsible Party is a Corporation, give ame and street
addr ss'of the Registered Agent'. �r}
�N me of registered Agent E-mail Address
-37
Current Mailing Address Current Street Address)
City e�State �/ Zip City; State Zip
Telephone —I p t � . (� � � b-& a Fax Number, "76-4 (*,3
The above information is;fue and correct to the best of my knowledge a 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;
('etcr� ,
Type or print name .. Title or Autho
Signature gate
I `".-,: a Notary Public of the County of 1, .
State of North Carolina, hereby certify thatrrn�rC� SIF appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him -
Witness my hand and notarial seat this 1 day of. V20 -2-2-
Notary 4
Seal
My commission expires
Tau Yang
NOTARY PUBLIC
Iredeil County, NG
My Commission Expires 12JO112025
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