NCC216558_FRO Submitted_20211123

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 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
a
2. Location of land -disturbing activity: County City or Township
VIighway/StreetAJ -Latitude .3r- B03411Longitude
3. Approximate date land -disturbing activity will commence: I',Cl( enC..�
4. Purpose of development resident€a commerc€al, industrial, institutional, etc.): __. gyi�/'itic:
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 0.6,7p Ac.
00
6. Amount of fee enclosed: $ I5AD-- An application fee of $176.00 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_l ,
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity.
Name I' �t DEO j coLA E-mail Address i �� �' Go r L + Ai f ul�;
Telephone 70ff''" . 5 9q!K1 Cell## lo` - 2 3S ^ 9V91 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
i [ k0W_-Tr�S V LPL 7 0 Ub `j
Name Telephone Fax -Number
_i J c S 1DW1 FEoo 6 LA0
Current Mailing Address
Hoy Svc GI. tic 17
City State - - - Zip
SAME
Current Street Address
City
State
10, Deed Book No. Page No. !�2& Provide a copy of the most current deed.
Part B,
Zip
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):
Name
_ J LJ[ S 10M(7C4100 Lf
Current Mailing Address
�tf?bi� 4'1G.L W-- 2S(17
City �t ct State ,Zip
Telephone 107 - IJ5� f 16 1
KE VI IJ V' _hde(:-2 l�t� ° (-Oil
E-mail Address
'Am&
Current Street Address
City State
Fax Number
Zip
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2. r (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 flame. 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
... '€he 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.
Signature
Title or Authority
Cate
I, �- tom' , a Notary Public of the County of l i (S U- t
State of North Carolina, hereby certify that _ i n 1� �1' n k 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 "ay of, a , 20
``t�E�tStiifillJJJJ/JJJJ,,
Notary _�1 1J )( J
Sealis \AOTAR`yr JV c7' C"Vl
�2-1
M My commission expires ,
MY
COMMISSION EXPIRES
Gj5J2021
Pia 13 00�.�
COU4 a1��g4y
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