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HomeMy WebLinkAboutNCC215817_FRO Submitted_20211103FINANCIAL 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 bradley.w.mills@zoetis.com Telephone (704) 657-2234 Cell # NIA Fax ## NIA Landowner(s) of Record (attach accompanied page to list additional owners): Amity Hill LCID, LLC (704) 657-2234 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 bradley.w.milis@zoetis.com Name E-mail Address 284 Barfield Road 284 Barfield Road Current Mailing Address Mooresville NC 28115 City State Zip Telephone (704) 657-2234 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 bradley.w.mills@zoetis.com 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 �� 2 0 =, o per gm' o Page 2 of 2