NCC220823_FRO Submitted_20220314

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 Name 6c. r. �$,L, &✓ f665 2. Location of land -disturbing activity: County^ r 111W City or Township
Highway/StreetQkf 9'%1 _Olfatitude35'. (o O� Longitude— 10, —j '7
ll
3. Approximate date land -disturbing activity will commence: Z. ! j o Z�
4. Purpose of development (residential, commercial, industrial, institutional, etc.): P.j� C ►,a1
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ (7>. 0e) . 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:
NameK;C Llc.l Wc.X E-mail Address M, JC.44w_rI la &,91 k0N.GS -C4fA
Telephone 7o(( -03 - y9y7 Cell # _ 1/.33 -99C17 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
AAf..( &.d �[bo��•4
Name Telephone
Fax Number
//3 N. tc.K.A.r Q. SvJc- (03 1\3 N• (ter►-ri-�t 4a--� iv,'4c Io-i
Current Mailing Address Current Street Address
��%,•t..tL�r tJc_ 02 77 N(. 25677
City State Zip City State Zip
10. Deed Book No.?_F7, __ Page No.. �7 . 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):
&)L5� /40"-<.4
Name
Current Mailing Address
E-mail Address
2;3t. 12e.L4VJ64 Dr'. , Srik
Current Street Addres
Mgtrrsvti(G OL 7 M0e1:2;-sydi- tut -
City State Zip City State
Telephone 100- 3:1 7 - -//g,3— 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 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
Telephone
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
provi corrected 'nform ion should there by any change in the information provided herein.
Type or print name
emt c. k .w &-60
Signature
Title or Authority
II I-t(z-2
DAte
, a Notary Public of the County of
State of North Carolina, hereby certify that mkt- M • WOO 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 20
r
,2Z
i`Laketa WAS Notary
NNW PUBLIC
Iredd Countyr NO
My Commission Expires June 22l 2022
My commission expir 22
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