NCC231711_FRO Submitted_20230605

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
(t.
EROSION & SEDIMENTATION CONTROL
IRED E L L No person may initiate any land-disturbing activity on one or more acres, 1/2 acre or more inside a
COUNTY NC 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 Honeycutt Flats
2. Location of land-disturbing activity: County Iredell City or Township Fallstown
Highway/Street Honeycutt Rd Latitude 35.663939 Longitude -80.90386
3. Approximate date land-disturbing activity will commence: February 15,2023
4. Purpose of development(residential,commercial,industrial,institutional,etc.): Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 3.25
6. Amount of fee enclosed:$ 200.00 . 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 Ryan Miller E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Dragon Properties 16, LLC 704-309-9880
Name Telephone Fax Number
131 Plantation Ridge Dr, Suite 2009
Current Mailing Address Current Street Address
Mooresville NC 28117
City State Zip City State Zip
10. Deed Book No. 2915 Page No. 672 Provide a copy of the most current deed.
Part B.
1. 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):
Dragon Properties 16, LLC [e-mail]
Name E-mail Address
131 Plantation Ridge Dr, Suite 200
Current Mailing Address Current Street Address
Mooresville NC 28117
City State Zip City State Zip
Telephone [phone] 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:
Michael Shott [e-mail]
Name E-mail Address
131 Plantation Ridge Dr, Suite 200
Current Mailing Address Current Street Address
Mooresville NC 28117
City State Zip City State Zip
Telephone [phone] 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:
Jay Shott [e-mail]
Name of Registered Agent E-mail Address
131 Plantation Ridge Dr, Suite 200
Current Mailing Address Current Street Address
Mooresville NC 28117
City State Zip City State Zip
Telephone [phone] 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.
Type or name Title or Authority
ign Date
I, ji—A.a tw. W ,a Notary Public of the County of Tr ed a 1'
State of North Carolina, hereby certify that T 5o n C• ,Sk 0 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 dog)da � 20 23
tary
Seal /
My commission expires co-87- Za 2 f
''f' OFFICIAL SEAL
'u� :4' .v Notary Public,North Carolina
�} ? County of Iredell
JUANITA W PADGETT
My Commission Expires G-27'-2-eZ11
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