NCC230857_FRO Submitted_20230329

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_f(//t� ff1�U1 k6(c"�6K /
2. Location of land -disturbing activity: County �—��� L City or Township 577FSy� •rlie_
Highway/Street STik di'f s}atitude 375 -)�390� N Longitude 9b. ct(5 q 5S010J
3. Approximate date land -disturbing activity will commencer
)j3�
4. Purpose of development (residential, commercial, industrial, institutional, etc.): ze5 o f774-f — 3S
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): I. 3 �,Ecrc
6. Amount of fee enclosed: $ ?)SD . 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name_ .":'� —Z-7-hw`S E-mail Address csrr;so,,- Tr.0q c �, c A*-e5 • WA&
Telephone f],�,Y-3io3 "Zdi5 Ceil# rlr1e Fax# t�
9. Landowner(s) of Record (attach accompanied page to list additional owners):
ra t434 .ryes LL r%�(- 3631!—
Name A1t3 Telephone Fax umber
4, -2cc> &tiel,Ey SG� �2� '� S �
Current Mailing Address
%f%4a & 14-- 2&//7
City State Zip
City
State
10. Deed Book No. °t� a Page No. 1sV`k ` \S 1 S Provide a copy of the most current deed.
Part B.
Zip
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):
/-�Nbo,g 90"res ILc cr�sen Tr,war�I-.hon+�s.��rn
Name E-m ddress
(:Z31306 W.-a LW 1 e
,CuIurrent Mailing Address
l/vldore5\- II e 1�14 L
City State
293 VI
Telephone 70`�- :?,6-j-Zaqs
Current Street Address
Zip City ))
Fax Number
State
Zip
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
Telep
E-mail Address
Current Street Address
City
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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State
Fax Number
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.
Type or prin name Title or Authorit
Sign tar Date
otary Public of the County of
State of North Carolina, hereby certify that U(Av Y �/1 V eared personal) before me this day
Y
and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this �,,day of YKL Z A
G. pq %, Notary
\. Jc Seal L/S
�GTARr My co ission expires
.,F PUBV'G �V``
Page 2 of 2