Loading...
HomeMy WebLinkAboutNCC221666_FRO Submitted_20220519FINANCIAL 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 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 Project Barkley - Building 2 2. Location of land -disturbing activity: County Iredell City or Township Statesville Highway/Street_E Barkley Rd Latitude 35.760647 Longitude-80.844579 3. Approximate date land -disturbing activity will commence: 6/1 /2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 20.0 6. Amount of fee enclosed: $ 3,500 . An application fee of $175.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 8.10-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 $100.00 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 Luke Bugenske Telephone 704.559.9456 Cell # E-mail Address Juke p�oak.engineering Fax #f 9. Landowner(s) of Record (attach accompanied page to list additional owners): Williams Development Group, LLC Name 331 High Street Current Mailing Address Winston-Salem, NC, 27101 City State Zip 336.529.6927 Telephone 331 High Street Current Street Address Fax Number Winston-Salem, NC, 27101 City State Zip 10. Deed Book No. 2857 Page No. 1182 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): Taylor Williams (Williams Development Group, LLC) Taylor@williamsdeveiopmentgroup.com Name E-mail Address 331 High Street Current Mailing Address _Winston-Salem, NC, 27101 City State Zip 331 High Street Current Street Address Winston-Salem NC 27101 City State Zip Telephone 336.529.6927 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: Name Current Mailing Address City State Zip Telephone E-mail Address Current Street Address City State Zip 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 State Zip Telephone E-mail Address Current Street Address City State Zip Fax Number 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 p�me Title or Authority Signature path 1, � ' Xan t't"� , a Notary Public of the County of 6_N� _ State of North Carolina, hereby certify that Y1 -r. w ttm f5 ,-5;-r _ appeared personally before me this day and being duly sworn acknowledged that the above was executed by him. Witness my hand and notarial seal, this z7� day of 20 Notary Seal My commission expires 20;LcS Page 2 of 2