NCC216815_FRO Submitted_20211209

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, 'Y2 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 Rocks Creek FreeJarN Uo,.Ies
2. Location of land -disturbing activity: County -Tr c6P.11. City or Township_ lroy+y.. a.
Highway/Street Qroo K Cfttk DF Latitude A (.&Zoo jgt4* Longitude ' $8. Sr�g ov�� y Gt L
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): _ Qe i J'Ji a l
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): _ 2, d 5
6. Amount of fee enclosed: $ Pftvsb„Vty Pa;d . 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 $135.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed ✓'
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name_ SoMa 0 IL PVT-ncv^ E-mail Address Sohn. Pv}haw•�FreecDar�`ya+�f1 cow.
Telephone o`(- SZ$^ �!9Ga Cell# 70q-'l0t^32Sc( Fax# ?_ Oy- S21-73Sr
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Telephone Fax Number
566o Clay¢., 506o Gta }e„ 12 •4J
Current Mailing Address Current Street Address
/44e.'! J k r- fN 3r V i I I e. , U C -31 6-D q
City '- State Zip City State Zip
10. Deed Book No. 2191 Page No. r46Y 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):
CM1-1 1-Ior^ef 1�
Name
S006 Clayio' Roa A
Current Mailing Address
7 / W--Clq
City State Zip
Telephone
3-061' f v�� M.,. *-frcGd.M
E-mail Address
boa GIk ��n 1ZOac�
Current Street Address
i"l�rru�lle. T•�/
?�ayl
City State Zip
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:
TONnCf 0"f" ICQv�'MFv. .• PV+hRN^m rtt.�or
Name E-mail Address
ltzK //Zy ChA, }t H-J
Current Mailing Address Current Street Address
T7rov4r *► NG Z?14& TCo-Jr,ar 66
City State Zip City State Zip
Telephone '�0'1 $ Z �- ?9 6 b 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:
l��cte�vr. Ooone o4 v6.' m gee
Name of Registered Agent E-mail Address
no) eti«la k ley., — I 111zq C a ok?c N-I
Current Mailing Address i Current Street Address
T oV4-w,,, /VC Z6-166 1'rov4-ma.,
City State Zip City State Zip
Telephone ` o h ' $Z g-_' q (.O 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.
30,fWl
Type or pint name (�
— � LL ---�
Signatur
1, _/,g .0-0
C.r'.(:r a% M"O' 5;cr
Title or Authority
1A I -'�)
Date
_, a Notary Public of the County of
,�iz�Dc GG
State of North Carolina, herebycertify that oHAI ?'' 41' A-�
fY 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 day of �E� , 20 2
Notary
Seal f
My commission expires
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