NCC215817_FRO Submitted_20211103

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, '/2 acre or more inside a watershed, as covered by the
Sedimentation Pollution Control Act and the Iredell County Land Development Code, before this form and an acceptable erosion
and sedimentation control plan have been submitted and approved by the Iredell County Development Services, Planning Division -
Erosion Control Section. (Please type or print,)
Part A.
1.
2.
3.
4.
5.
6.
Project Name Ozark Avenue, LLC, LCID
Location of land -disturbing activity: County Iredell City or Township Statesville
Highway/Street Amity Hill Road Latitude 35.696754 Longitude -80.819316
Approximate date land -disturbing activity will commence: ASAP
Purpose of development (residential, commercial, industrial, institutional, etc.): LCID Landfill
4 Acres New
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7 Ac. Total Q Ac. previously Permitted)
Amount of fee enclosed: $ 700.00 . 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 .5 acre but < 1.0 acre
in a water supply watershed, a flat fee of $135.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
Q
9.
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bradley Mills E-mail Address [e-mail]
Telephone [phone] Cell # NIA Fax ## NIA
Landowner(s) of Record (attach accompanied page to list additional owners):
Amity Hill LCID, LLC [phone] NIA
Name
284 Barfield Road
Current Mailing Address
Mooresville NC 28115
City State Zip
10. Deed Book No. 2608
Part B.
Telephone
284 Barfield Road
Current Street Address
Mooresville
City
Fax Number
NC 28115
State Zip
Page No. 571 Provide a copy of the most current deed.
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):
Amity Hill LCID, LLC [e-mail]
Name E-mail Address
284 Barfield Road 284 Barfield Road
Current Mailing Address
Mooresville NC 28115
City State Zip
Telephone [phone]
Current Street Address
Mooresville NC 28115
City State
Fax Number NIA
Page I of 2
WE

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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number
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:
Bradley Mills
Name of Registered Agent
284 Barfield Road
Current Mailing Address
Mooresville NC
City State
Telepho
[e-mail]
E-mail Address
284 Barfield Road
Current Street Address
28115 Mooresville NC 28115
Zip City State
Fax Number
WE
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.
Bradley Mills
Type or print name
ds!a,j
/Y-Z!W
Sign ture -
Owner 1 Agent
Title or Authority
Date
'e- , , a ni- a Notary Public of the County of
State of North Carolina, hereby certify that �� �Q e�! e_I/ Tel a it _S 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 0 day of 20 y
Tt
`eat �Oc I
r4 lA u ZO)Mmission expires
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