NCC242154_FRO Submitted_20240716

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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EROSION & SEDIMENTATION CONTROL
IREDELL No person may initiate any land-disturbing activity on one or more acres, '/z 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 Brooke Forest (Lots 1, 4-7, 9, 13-19)
2. Location of land-disturbing activity: County Iredell City or Township Mooresville
Highway/Street Didio Circle Latitude35.64053 Longitude-80.835831
3. Approximate date land-disturbing activity will commence: 05/2024
4. Purpose of development(residential,commercial, industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 9'49 Acres
6. Amount of fee enclosed $1,750 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 I No _ —Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name
Henry Kirchner E mall Address Henry.Kirchner@centurycommunities com
Telephone [phone] Cell# 704-600-8456 Fax#
9 Landowner(s)of Record(attach accompanied page to list additional owners):
Century Communities Southeast, LLC 704-754-5460
Name Telephone Fax Number
7401 Carmel Executive Park Drive 7401 Carmel Executive Park Drive
Current Mailing Address Current Street Address
Charlotte NC 28226 Charlotte NC 28226
City State Zip City State Zip
10. Deed Book No 3044 Page No.90-92 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):
Century Communities Southeast, LLC [e-mail]
Name E-mail Address
7401 Carmel Executive Park Drive 7401 Carmel Executive Park Drive
Current Mailing Address Current Street Address
Charlotte NC 28226 Charlotte NC 28226
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:
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:
National Registered Agents, Inc.
Name of Registered Agent E-mail Address
160 Mine Lake Ct. Ste 200 160 Mine Lake Ct. Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
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.
Henry Kirchner Senior Vice President of Land Development&Operations
Type r print name Title or Authority
0/4,1
S gr atv e Date
I. S. 117c. 4, v )ULJ\ r-e ,a Notary Public of the County of 1�1-vv
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State of North Carolina, hereby certify that 1"`err)I \1c CV A O a� appeared personally before me this day
and being duly sworn acknowledged that the above fo was executed by him. 1
Witness my hand and notarial seal,this '3) day of 1 1 K'>:..�) ,20 ptk-1
Notary .3
Seal
\\\\``0�� IiROil��/ My commission expires
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to Mecklenburg rn
County My Comm. Exp.
12-15-2024 Q'
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