NCC242042_FRO Submitted_20240718

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IR f: I )E: 1_ I_ No person may initiate any land-disturbing activity on one or more acres, '/z 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 plan has been submitted
and approved by the Iredell County Planning& Development, Erosion Control Section.
(Please type or print)
Part A.
1. Project Name Kilburn Court Apartments
2. Location of land-disturbing activity: County Iredell _City or Township Mooresville
Highway/Street Whitman Circle Latitude 35.606 Longitude -80.814
3. Approximate date land-disturbing activity will commence: Jan. 8 2024
4. Purpose of development(residential,commercial, industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 5.5
6. Amount of fee enclosed:$ 1050 . 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 Jerry DeCarlo E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9 Landowner(s)of Record(attach accompanied page to list additional owners):
2357 Statesville Hwy LLC 704-360-2874
Name Telephone Fax Number
117 Crosslake Park Drive
Current Mailing Address Current Street Address
Mooresville, NC 28117
City State Zip City State Zip
10. Deed Book No 2765 Page No 185 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):
2357 Statesville Hwy LLC
Name E-mail Address
117 Crosslake Park Drive
Current Mailing Address Current Street Address
Mooresville, NC 28117
City State Zip City State Zip
Telephone [phone] Fax Number
Page 1 of 2

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:
Dominic Ferrovecchio
Name E-mail Address
117 Crosslake Park Drive
Current Mailing Address Current Street Address
Mooresville, NC 28117
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.
1)0(Y\t n 1 C. {t.((0 ¢ V c l,- i. VW-41 Vo-L..-
Type or a �Vr'1 Title or Authority
. 1 \ \a Ci )
Signatur Date
I. e-S S I(-4 OAAIA ,,a
llotary Public of the County of tlr`� l-44(42(-4-4-12-er
State of North Carolina, hereby certify that 1-OFYLkn,C. (—e_((7✓Q(l C- O appeared personally before me this day
and being duly sworn acknowledged that the above form was executed by him.
,/4t..
Witness my hand and notarial seal,this 4_ / day of KIDU /_2 3 D
cA_
6,G✓�Nota
Seal 51c23 I�
My commisson expires
JESSICA CAIN `�
Notary Public, North Carolina
Mecklenburg County
My Commission Expires
May 23,2027
Page 2 of 2

♦ye-,taas�ef`,
'4 Town f Planning and Community Development Department
1 o r� 11 0 413 North Main St.,Mooresville,NC 28115
Mooresville 704-662-7040
�NOtt,*c
Agent Authorization(to be completed by each owner)
The undersigned owner,does .hereby authorize: p ,I
Agent Name: ) Kit lu &G� l&U' Address: 7 a'1 IY1&in St-
Telephone: 331O— 8 38 —c tO h%ot•+In Wilk& (a:rc)
E-Mail Address: Jesse @ r i G t . U e
to act on my behalf for the purpose of petitioning the Town of Mooresville for:
_Special Use Permit
Variance
_Rezoning
as applicable to the property described in the attached petition.
The owner does hereby covenant and agree with the Town of Mooresville that said person has the authority to
do the following acts for and on behalf of the owner:
1. To submit a proper petition and the required supplemental materials;
2. To appear at public meetings to give testimony and make commitments on behalf of the owner;
3. In the case of a conditional rezoning request,to accept formal conditions for the project;
4. To act on the owner's behalf without limitations with regard to any and all things directly or indirectly
connected with or arising out of the request.
The authorization shall continue in effect until final disposition of the petition submitted in conjunction with
this reque
1I 2Cil 23
Signature of P erty Owner Date
bUncll I C TeX L'el ‘�
Printed Name
OrYU rl i h Fe(iL VP L(1 ki 0 personally appeared before me this day and
acknowledged the witness by my hand and official seal this the Z_ day of AJOiJ&11 tom, 2O. 2 3
Notary Pu lie,My Co mission Expires 610?3/
JESSICA
Notary Publicc,. North
Carolina
Mecklenburg County
My Commission Expires
May 23,2027