NCC230258_FRO Submitted_20230216

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Part A.
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, 'Y2 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.
1. Project Name Bluefield Road
2. Location of land -disturbing activity: County Iredell City or Township Mooresville
Highway/Street Bluefield Rd.
Latitude 35.6031 Longitude -80.8639
3. Approximate date land -disturbing activity will commence: 10/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Multi -Family Apartments
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.98
6. Amount of fee enclosed: $ 2,800.00 . 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 Josepth Boulos, PE
Telephone [phone]
Cell #
E-mail Address joe [e-mail]
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bluefield Apartments, LLC
Name
5800 Old Pineville Rd.
Current Mailing Address
Charlotte NC
City State
10. Deed Book No. 2842
Part B.
Telephone
Current Street Address
Fax Number
28217 Charlotte NC 28217
Zip City State Zip
1207, 1212,
Page No. 1216, 1220 Provide a copy of the most current deed.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all
responsible parties jon an attached sheet,))::
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Name �� E-mdl Address
57500 dU hwyrlh. &LA- 20l rg,049 A/W Alaeeftr zq
Current Mailing Address Current Street Address
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City State Zip City State Zip
Telephone !R f ' ,07. fZl/.!r Fax Numbers/X
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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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip 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
Telephone,
E-mail Address
Current Street Address
Zip 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.
6MXVIA
1 V, 4K4"(_-
Type or print name Title or Autha ty
' - Z 022
Signatur Date
a Notary Public of the County of
State of North Carolina, hereby certify that C •asoil �-LC--hf�Lappeared 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 —7-6` day of t-- 20 ZZ.
C
Notary
Seal
SLISA KING AND
a NOTARY PtaUC:
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My commission expires
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