NCC241901_FRO Submitted_20240621

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
CO EROSION & SEDIMENTATION CONTROL
IREDELL No person may initiate any land-disturbing activity on one or more acres, % acre or more inside a
COUNTY NC 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 Society Manor
2. Location of land-disturbing activity: County Iredell City or Township
Highway/Street Vaughn Mill Rd Latitude 35.8976 Longitude -80.7221
3. Approximate date land-disturbing activity will commence: June 1, 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.66 AC
6. Amount of fee enclosed: $ 875 . 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 Katie Dyess E-mail Address [e-mail]
Telephone [phone] Cell# Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
MartinRay Holdings, LLC 704-658-1121
Name Telephone Fax Number
114 Morlake Drive Suite 103
Current Mailing Address Current Street Address
Mooresville NC 28117
City State Zip City State Zip
10. Deed Book No. 3042 Page No. 1421 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):
WJH LLC [e-mail]
Name E-mail Address
8390 E. Crescent Parkway Ste 650
Current Mailing Address Current Street Address
Greenwood Village CO 80111
City State Zip City State Zip
Telephone [phone] 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:
CT Corporation System
Name E-mail Address
160 Mine Lake Ct Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] 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 th e by any change in the information provided herein.
Kurt Stawarz Mid Atlantic Regional President
Type or p ' t name Title or Authority
.�/'/0021
nature Date
1 C.v.'.t+ ,rcl t.S1a'
L.
I. a.w✓,C 5. 14111.
`"..J . a Notary Public of the County of Ge SWba
State of North Carolina, hereby certify that Kurt Stawarz 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 I day of M a ,20 2.4
o ry
Seal
My commission expires I— (i- 2 OZq
LAURIE S. HOGLU.ND
Notary Public, North Carolina
Guilford County
My Commission Expires
01-0&2029
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