NCC230077_FRO Submitted_20230111

Financial Responsibifit /Ownership Form Sedimentation Pollution Control Ordinance
No person may initiate any land -disturbing activity on one or more acres as covered by the ordinance before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Rowan County
Environmental Management Department.
Part A Parcel ID Number
456-160, 456-161,
456-162 & 456-163
1. Project Name*
Betty Raney Meadows Lots # 2-5
2. Location of land -disturbing activity (Highway/Street)*
4815, 4775, 4765 & 4755 Sherrills Ford Rd
Latitude
35.68713330
Longitude
-080.5691556°
3. Approximate date land -disturbing activity will be commenced
2/1/2023
4. Purpose of development (residential, commercial, industrial, etc.)
Residential
5. Approximate acreage of land to be disturbed or uncovered*
2.6

Phone Number
[phone]
Phone Number
a. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of a North Carolina
Agent.
Name of Agent Name of Agent
II
Current Mailing Address Current Mailing Address
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Phone Number Phone Number
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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 the name and street
address of the Registered Agent.
Name of Registered Agent
Todd Farlow
Current Mailing Address
116 Raceway Dr, Suite 105
Mooresville, NC 28117
Telephone Number
[phone]
Current Street Address
Telephone 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 authority to execute instruments for the Financially Responsible Person).
I agree to provide correctional information should there be any change in the information provided herein.

b. Person to contact should sediment control issues arise during land -disturbing
activity*
James Legg
'this information wdl be made awffabM on the Rowan Cou._� Plannln & D' --
mY 9 �aP+a�i webslts.
Email Address
[e-mail]
7. Landowner of Record
Helmsman Homes, LLC
Name
Current Mailing Address
116 Gasolina Alley, Suite 105
Mooresville, NC 28117
S. Recorded in Deed Book Number
'weed--?>nk I14/s'
Part B
1. Person or Firm who are financially responsible for this
land -disturbing activity
Helmsman Homes, LLC��
Name of Person(s) or Firm(s)
Current Mailing Address
116 Gasolina Alley, Suite 105
Mooresville, NC 28117
Cell Phone Number*
_- _ 7 [phone]
Landowner of Record
Name
Current Mailing Address
I
i
f
Page Number
i
Person or Firm who are financially responsible for this land -
disturbing activity
Name of Person(s) or Firm(s)
Current Mailing Address

Name
f .
Todd Farlow
Signature
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Title or Authority
Legal Counsel
i
Date
mmlddlyyyy
.......................................................................................................................................................................................
L a ` J s-kba Notary Public of the County of 4. - c, t i State of North Carolina,
hereby certify that r d o appeared personally before me this day and being duly sworn acknowledged
that the above form was executed by him/her. Witness my hand and seal of Notary, this Q, day of _ l'..t eAPOLe.- , 20 Z.?-
Notary My commission expires
f `�prprtirmrrpph. '
Seal
Checklist a C
Download a copy of the Erosion and Sedimentation
Control Plan Checklist (PDF) C •'