NCC230481_FRO Submitted_20230425

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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 Ian has been submitted
and approved by the Iredell County Planning & Development, ErosiolI, /ED
Part A. NOV 0 3 202a
1. Project Name Southfork LLC _ Lot 4
2. Location of land -disturbing activity. County
Iredell
Cityor Township Mooresville
Highway/StreetBarley Park Lr:Latitude Longitude
3. Approximate date land -disturbing activity will commence- 11-15 - 2 0 2 2
4. Purpose of development (residential, commercial, industrial, institutional, etc.)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
COMMERCIAL
2.49
6. Amount of fee enclosed: $ 525 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name n ��y Cro cfl�y
Telephone 70 V - 577 10 Z/ Cell #
E-mail Address K4 L4y (?� a d 1 P�o�' �Y ' Co Al
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Fax #
50 G a<4 row �i n nV12Vi ��! LLC 7 o V -1 71 4o ZZ
Name Telephone
Fax Number
PO /3aX 11VO .7O 9 S<o Re fk/svosod Lone
Current Mailing Address Current Street Address
4.150 roe /, •vr A-CL Z *63 / arose A-•t N [
City State Zip City State - Zip
10. Deed Book No. 2334 page No. 1837 Provide a copy of the most current deed.
Part B.
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):
50 C4 �-4 /1'a a s rrs u
Name
Rox //yo
Current Mailing Address
am t l - /1r4 Z YO 3 /
City State Zip
Telephone 7 0y- 5-17 7^ f O Z/
&a �-4 a ojo_ILC% oe rr co,y
E-mail Address
a ag c/o /3e AAAwooW La-,f
Current Street Address
Cor,.e/'vs /VIC 2S03/
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 Parry 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.
Type or print name
Signature
/f4naj er
Title or Authority
io - 24- Za z 7-
Date
1,2100A 0 - �� t�5_ a Notary Public of the County of
State of North Carolina, hereby certify that _ t L� �h n C'a0 d 1 e4 appeared personally before me this day
and being duly sworn acknowledged that the above form w9 executed by hitri.
Witness my hand and notarial seal, this =day of tW 20 ��-/ /y��
A Lff _��
Notary ' T
Seal '3021" -o My commission expires
1
RONALD N. TITUS
NOTARY PUBLIC
Mecklenburg County
North Carolina
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