NCC221936_FRO Submitted_20220523

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 lredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the lredell County Planning & Development, Erosion Control Section
(Please type or print )
Part A.
1. Project Name First Resurrection Church
2. Location of land -disturbing activity: County lredell City or Township Statesville
Highway/Street Shelton Ave Latitude 35.764790 Longitude -80.885330
3. Approximate date land -disturbing activity will commence' January 1st, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Church
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas); 3.2
6. Amount of fee enclosed $ ��, 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:
Name E-mail Address la'"CG.?Q�/9�i4d. �'DiYI '000, Sl
Telephone Cell # 7r��- o�f` ��33 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners) -
First Resurrection Church 16Y-W 2-GJ"T.3
Name Telephone Fax Number
10
PO Box 5381
Current Mailing Address
Pe-Be*z"
Current Street Address
Statesville, NC 28687 Statesville, NC 28687
City State Zip City State
Deed Book No. — 9-701 rage No.w'� Provide a copy of the most current deed.
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Part B.
Zip
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of al!
responsible parties on an attache
First Resurrection Chur�OOW 140TYig j ,�N�,G2
Name +; UOD I.009+1 E-mall Address
1100
PO Box 5381 r' � o,qx rnow, _ _ i 5z li,, A
sengx3 na�s4 ncnoD+fM a b
Current Mailing Address--' Current Street Address
Statesville, NC 28687 r4 jaylyl` &c— �2#?
City State Zip City state Zip
Telephone 9 4,,1- i keg -Dk73 Fax Number
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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
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Telephone Fax
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 by any change In the information provided herein.
.:<dr✓rlliE 6, 62Qc/ 0�ql5wee
Type or print name Title or Authority€
Signature Date
n - A--- - - - l . i .
I, , allotary Public oftheCounty of 1 G[tW !
State of North Carolina, hereby certify that &s^AlL t� appeared personally before me this day
and being duly sworn acknowledged that the above form was eJxecut d by him.
Witness my hand and notarial seal, this :24
day of a� b .20
Seal
Notary
My commission expires L
PEYTON WOODY
NOTARY PUBLI
lredell County
North Carolina
my Commiuion Expires
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