NCC223730_FRO Submitted_20221109

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 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 a Ire-dell
2. Location of land -disturbing activity: County Zr e-de / 1ii
City or Township T�-e, cl
HighwaylStreet M 0wko_ %V & I en Pr
Latitude Longitude
3. Approximate date land -disturbing activity will commence. 1 Q 1 Z 4 % 2 C74Z
4. Purpose of development (residential, commercial, Industrial, institutional, etc.): re S id eel �l
S. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3. R Z
6. Amount of fee enclosed: $ "LD 0 • D C! An application fee of $175.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a a.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.
T. 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 A ) 0� OL l Address 601,__``I' i C[M
Telephone Cell # 704- 88 `— 6 H4 lax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
�3YS �I'lyes�rneh} 2, L-1 _ -7D4 82 j _624
Name Telephone Fax Number
1 ZS7VW, Mp-e hoosf Ave- S6kwt4_
Current Mailing Address Current Street Address
Meer asyl'I11P ANC. _290 54kWL_0__
City �7 State Zip City State Zp
10. Deed Book No. � � f � Page No. 03 '" � Provide a copy of the most current deed.
Pert S. 2_8 008
%0 -- 116 -2 -
9"y, at; I - C,0,
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list or all
responsible parties on an attached sheet):
I Achim,- Abdo — Mu!Iade L Lis hctr, a wC
Name E-mail Address
1 Ls W Mior6%cost? Ave- -Sa wk.�
Current Mailing Address Current Street Address
r V I" 1 I¢. Nt 2-9117
City stale Zip City State Zip
Telephone 1 041- K I— 6 Z Fox 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 Melling Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Parry is a Partnership or other person engaging in business under an assumed name, attach
a cOpY of the Certifiats of Assumed Name. If the Financially Responsible Party is a Corporation, give name and street
address or the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 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
Provide corrected Information should there by any change in the information provided herein.
CA-vc w- ; O tj ~ Mayede- k. H em r 1 Motr%eL� e-r
Type or print name Title or Author y
signal Jo
Date
I, MOVIK I �r �I,iar+ a Notary Public of the County of 1red e. I1
State of North Carolina, hereby certify that Fwckcur Pr -MIS ql eI. 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 P`i'*' day of , 20 Z-Z
olary
Seal
F
k J Lightontary Publicil County, NCn Expires June 19, 2023
My commission expires_ ot'-1I'f'izOZ-3
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