NCC220728_FRO Submitted_20220303

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/or fax information
unavailable, place N/A in the blank.)
Part A.
Project Name Liberty Park Phase 2
Location of land -disturbing activity: County Iredell City or Township Mooresville
Highway/Street East Iredell Ave. Latitude 35.583283 Longitude-80.808191
3. Approximate date land -disturbing activity will commence: July 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Civic
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.6 AC
6. Amount of fee enclosed: $ 455 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Nick Lowe E-mail Address nlowe(&-mcadamsco.com
Telephone [phone] x360 Cell # 704-239-5088 Fax # _
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Mooresville 704-799-4298
Name Telephone Fax Number
PO Box 878 413 North Main Street
Current Mailing Address Current Street Address
Mooresville NC 28115 Mooresville NC 28115
City State Zip City State Zip
10. Deed Book No. 1198 Page No. 244 Provide a copy of the most current deed.
Part B.
Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Town of Mooresville cwyckoff _mooresvillenc.gov
Name E-mail Address
PO Box 878
Current Mailing Address
Mooresville NC 28115
City State Zip
Telephone [phone]
413 North Main Street
Current Street Address
Mooresville NC 28115
City State Zip
Fax Number

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 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 Name. 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
Telephone 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 be any change in the information provided herein.
Randall W. Hemann
Type or pri t�name
W
Signature
Town Manager
Title or Authority
Date
I, S'1V .,j1tJft C: IDL5CY- , a Notary Public of the County of rTcjtA I�
State of North Carolina, hereby certify that 11�0.n8011 .. "r-mana 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 \ a)rday of NZkQbrav — , 20��
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