NCC220550_FRO Submitted_20220127

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 AUGUSTA GREENS SUBDIVISION -LOT 16 - 20, 70 & 74
2. Location of land -disturbing activity: County IREDELL _ City or Township STATESVILLE
TOP FLITE DR. &
Highway/Street TAYLOR MADE ❑R. Latitude N35° 45' 09.12" Longitude W810 02' 16.24"
3. Approximate date land -disturbing activity will commence: FALL 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.45 AC.
6. Amount of fee enclosed: $ $ 428.75 . 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name TIM GRISSINGER E-mail Address [e-mail]
Telephone, 919.577.1080 Cell # -- Fax # --
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BULLER RIVER DEVELOPMENTS 803.830.5459
Name Telephone Fax Number
234 KINGSLEY PARK DRIVE, SUITE 110
Current Mailing Address
FORT MILL, SC
City
10. Deed Book No. 2845
Part B_ 2855
State
29715
Zip
Page No. 626
70
Current Street Address
City State
Provide a copy of the most current deed.
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):
CORNERSTONE III PROPERTIES, LLC. [e-mail]
Name
234 KINGSLEY PARK DRIVE, SUITE 110
E-mail Address
Current Mailing Address Current Street Address
FORT MILL, SC 29715
City State Zip City State
Telephone [phone] Fax Number
Zip
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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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State 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 istered gent:
Name of Registered A t E-mail Address
Current Mailing Address
city
Telephone
Current Street Address
State 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
provide corrected information should there by any change in the Information provided herein.
Type or print name }} ,, Title or Aut rity
J Ir P
Signature ate
a Notary Public of the County ofUn
State of North Carolina, hereby certify that s6nll fr VV a PE'%lify-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 2day of 2021
Notary &C-1),Z)
Seal My commission expires , • �C]
Emilio Castro -Martinez
NOTARY PUBLIC
Unlon County
North Carolina
My Commission Expires 11/02/2026
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