NCC221633_FRO Submitted_20220518

Part A.
FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Iredell County Land
Development Code, before an ble
plan h
and approved by the IIredell County Planerosion ning &Developmensedimentation
t Erosion Ccontrol ntrolSectionn been submitted
(Please type or print.)
Sri �DG� s mag , a9, a I ".V
1. Project Name /dj /O I/Q
S J QE �..L City or TownshiAftff&V&49
2. Location of tang-�i� � activity: County
Highway/Street9Oo7. Latitude Longitude
$7A446 EDGE Ti Ti�N/um xIRCPi✓ s fX( .20
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional. etc.): 051 oF,dTl"
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
8. Amount of fee enclosed: $ . An application fee of $175.00 per acre (rounded up to the next acre) is
arealer$han 0.99 acreslin in a water supply watershed,, a ilai fee of application
00 OOes assessed.
projects � than 0.5 acres but no
9
7_ Has an erosion and sediment control plan been filed? -Yes_ Na
Enclosed_ff-
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Nam p s�f3/V P/t FrsLFr E-mail Address '
Telephon7AA/
Cell # a` Fax #
g. Landowner(s) of Record (attach accompanied page to list additional owners):
�•,/]ER RI�FR 1�KT go •S3o. �fl'" X
Name
Telephone Fax Number
.2yet , ,�le�sLEy �i�P�' Ox Vlyr //
Current Mailing Address Current Street Address
City
State Zip City State Zip
PageNois8 Provide a copy of the most current deed.
10. Deed Book No.. �'
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):
F o�nr xc E3 Cosy E-mailil Address
Name
or�.
Current Mailing Address Current Street Address
.a /Ill. 2 g7/S zip
State Zip city State
City / Jve
Telephon < Fax Number
Page 1 of 2

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:
oAL• XP,
Name E-mail Address
..1 l �rry
Current Mailing Address Current Street Address
-nrl[r /t%rLL C City State Zip
City State Zip
Telephone 3d 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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
State Zip
Telephone Fax Number
y me under
ath
is
form
The above information Financ alltrue and
correct tthe best of my knowledge and belief and was Resp nsible Person if anind vidual or his attorney-in-fact,roori f otban nd viduall,, by nhofficer,
must be signed by the F Y
director, partner, or registered agent with the authority to execute instruments for the Financially Responsible Person}. [agree o
provide corrected information should there by any change in the information provided herein.
Type or print name
Title or Authority
Date
Signature, 37
a Notary Public of t e County of
I/ WILL -
appeared personally before me this day
State of North Carolina, hereby certify that
and being duly sworn acknowledged that the above form was execute by him.
20
Witness my hand and notarial seal, this &day of'^
TIFFANY4NANCZECA EXUM My
NOTARY PUBLIC
Union County
North Carolina
My Commission Expires Aug. 16,2026