NCC215726_FRO Submitted_20211015

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
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 Cie) � (' ' "� k 1 b 6 J k` ` U n
2. Location of land -disturbing activity: County ! Y k� City or Township -1-(GtJ k-n \\&'1
Highway/Street Latitude ,& Longitude
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): 'pNe'o &EA h c
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14?j
6. Amount of fee enclosed: $ K.i � � . 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 is assessed.
7. Has an erosion and sediment control plan been filed? Yes ) , No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Named } `'e Ca (0kE-mail Address ca((Q tl D9_1- Co (+un GQYJ
Telephone -j0y _ ---j` ?3 Cell # ;1 ,dam® E Fax #
9. Landowner(s) of Record (attach arrc��companied page to list additional owners):
Name V Telephone Fax Number
UGC)1 'QiVFiti®1 4_e_ qQ0
Current Mailing Address Current Street Address
&v pe r1 i\c SC-.. o 1
City State Zip City State Zip
10. Deed Book No. _ j 7 Page No. i O - (Gska 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):
IN
?i'N I a f— &XAl_ CcrIok I-V,^ cti�,�Ail C� D2{-aca�
Name I E-mail Address
_Bno'Q\.'JCA
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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
ISU fIt-u P t ic. z l if s fi
Current Mailing Address Current Street Address
L 1c. C4 L, AJ- d"lhUi
City
State
Zip City
Telephone( q - (6�,) t - < 3 Fax Nu
State Zip
(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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
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
provi e corrected information /+/1should there by any change iin%the information provided herein.
I lam! G b � V � e� t/` ® ,i �44L4
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Ty p r print n me Title or Authority '
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natu
Date
I, Rc"LGl)e( UO_V- - V\ �- y�S , a Notary Public of the County of 661s4w)
State of North Carolina, hereby certify that 61ea e Ra-yi-kL Ca-I'v'j ( I appeared personally before me this day
and being duly sworn acknowledged that the above Yorm was executed by him.
Witness my hand and notarial seal, this L-i day of DC4-DbC_ V_ , 20 ,-(
Seal Notary
My commission expires _,uO 4
Rachel Martin Hayes
NOTARY PUBLIC
Gaston County
North Carolina
My Commission Expires May 27, 2025
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