NCC221327_FRO Submitted_20220406

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, % acre or more inside a
watershed, as covered by the Sedimentation Pollution Control Act and the fredelf County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredelf County Planning & Development, Erosion Control Section.
(Please type or print.)
Part A.
1. Project Name SULLIVAN FIELDS
2. Location of land -disturbing activity: County IREDELL City or Township CONCORDBETHANY
Highway/Street SULLIVAN FARM ROAD Latitude 35.9247416 Longitude-090.9136154
3. Approximate date land -disturbing activity wili commence: APRIL 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.73
6. Amount of fee enclosed: $ 2,450 . 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 MICHAEL WETTER E-mail Address mwetter®nesthomes.com
Telephone [phone] Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
SULLIVAN FARMS DEVELOPMENT, LLC
Name Telephone Fax Number
PO BOX 3965 236 RACEWAY DRIVE, SUITE 7
Current Mailing Address Current Street Address
MOORESVILLE, NC 28117 MOORESVILLE, NC 28117
City State Zip City State Zip
10. Deed Book No. 2867 Page No. 2069 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 fist of all
responsible parties on an attached sheet).
SULLIVAN FARMS DEVELOPMENT, LLC [e-mail]
Name E-mail Address
PO BOX 3965 236 RACEWAY DRIVE, SUITE 7
Current Mailing Address Current Street Address
MOORESVILLE, NC 28117 MOORESVILLE, NC 28117
City State Zip City State Zip
Telephone [phone] Fax Number
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(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
Telephone 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 Registered Agent:
TODD JASON FARLOW
Name of Registered Agent
Current Mailing Address
State
E-mail-4-c- 6 ' -
Address
d
Current Street Add s
Zip ' City
TelephonFax 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 attomey-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
providLrrected information should there by any change in the information provided herein.
Typ or print na Title or Au '
y
Signa re Da
ca a Notary Public of the County of
State of North Carolina, hereby certify that /�e"xecu�tedby
and being duly sworn acknowledged that the ove form im appeared personally before me this day
Witness my hand and notarial seal, this day of 20�
Seal
Notary
Uaketa Davis
WARY PUBUG
�We1j
County, IVC
iMy Commssion Expires
June 22, 2022
My commission expires
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