NCC233812_FRO Submitted_20240103

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
. EROSION & SEDIMENTATION CONTROL
IR L D L L L No person may initiate any land-disturbing activity on one or more acres, 1/2 acre or more inside a
nil 1st N c 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 Dollar Avenue
2 Location of land-disturbing activity: County Iredell City or Township Troutman
Highway/Street US Hwy 21 Latitude 35-66-54 Longitude-80-85-14
3 Approximate date land-disturbing activity will commence: December 2023
4 Purpose of development(residential, commercial, industrial, institutional,etc.): Commercial
5 Total acreage disturbed or uncovered(including off-site borrow and waste areas): 3.96
6 Amount of fee enclosed: $700 . 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 flat fee of$135.00 isassessed.
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 Howard Bryan E-mail Address hfbpiedmontrealtvCa)vahoo com
Telephone [phone] Cell# Fax#
9 Landowner(s)of Record(attach accompanied page to list additional owners):
Piedmont Landco, LLC [phone] [phone]
Name Telephone Fax Number
PO Box 1654 940-B Davie Avenue
Current Mailing Address Current Street Address
Statesville, NC 28687 Statesville, NC 28677
City State Zip City State Zip
10. Deed Book No. 2938 Page No 1335 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):
Piedmont Landco, LLC hfbpiedmontrealtyayahoo com
Name E-mail Address
PO Box 1654 940-B Davie Avenue
Current Mailing Address Current Street Address
Statesville, NC 28687 Statesville, NC 28677
City State Zip City State Zip
Telephone[phone] Fax Number(704) 873-0501
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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 corrected information should there by any change in the information provided herein.
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Signature Date
, a Notary Public of the County of ire. ���
State of North Carolina, hereby certify that \'‘'-(*) 4l .r\ appeared personally before me this day
and being duly sworn acknowledged that the above form was executed byhim.
Witness my hand and notarial seal,this4-{ day of �vt62..r,20
Notary
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