NCC232543_FRO Submitted_20230823

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IRE D E L L No person may initiate any land-disturbing activity on one or more acres, 1/2 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
1. Project Name S ciY CJt_S JrF (Cl
2. Location of land-disturbing activity: County t reO-E l City or Township 1-60OYeSU t 'e.
Highway/Street w-I o-I Latitude 3 j,(o (act Longitude —80- 8 3 u 9
3. Approximate date land-disturbing activity will commence: Se e(Noel- 6/CCa.3
4. Purpose of development(residential,commercial, industrial, institutional, etc.): Rt'' t. (\4 1Gl
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): I (q 0
6. Amount of fee enclosed: $ N A . An application fee of$175.00 per acre(rounded up to the next acre)is
assessed without a ceiling amoun't (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 X. No Enclosed
8. Personto--contact should erosion and sediment control issues arise during land-disturbing activity:
nn
Name 1. COS c Fi r o E-mail Address C.tcOe.f1#-I r1GJi2t4-o ('fr.cl_ CO en
Telephone qQ - 9`1S -M474 Cell# q 86--$7c' Ob b "I Fax# r'k./ !A
9. Landowner(s)of Record(attach accompanied page to list additional owners):
D Z _ nr+un Ir1L 4$t?-P,1S-Netaq t .)
Name Telephone Fax Number
Boos IA-rrOLoft dv. P tXd.1 csas err O ri S1 o eAw . 1
Current Mailing Address Current Street Address
Ch CAA ck,w a93-13
City State Zip City State Zip
10. Deed Book No. [() Page No.86,._g 13 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):
D. iZ_ (-k (+o rN)Inc__ GI cos e.f' @Del-o 1#O n_ to.W'\
Name E-mail Address
220sIS AY(OW 't ikq 0a.S Ick-rrow ri [€. (3t.id
Current Mailing Address Current Street Address
ChM W WC- . 13 Ch o_r to+4c c., Q-8 3:7'3
City State Zip City State Zip
Telephone q Fax 80 — - e 0 6 47 Fax Number iV
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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 Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
CT Coiporn-ior, Sysk-tre i o ,c ad►van+o ,,e _ cGvv)
Name of Regfstered Agent E-mail Addr s
i( U V"'i i ant lul,_ (fr. .i-e-aov M i l WAG C- , i S I-e_aoo
Current Mailing Address Current Street Address
___(?“ 4 � f h N tllo1S �' le.►yh `)C- a--7(otS
City ,1 rSttate Zip City State Zip
Telephone (( I 1 - �/ 1 -1 13 IC� Fax Number Ni i A
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.
COCLA ecrSe, t4i0 t, nivKI0n NI ADGS -rah Comp A-Amin
Type or ritit name Title or Authority
2 — Vc)--1 /Signatur D
I, Racket a-v4;rx kcuj fS ,a Notary Public of the County of 61C4_5+0Y\
State of North Carolina, hereby certify that CO(lt.� C �.V-�OS + in 0 appeared personally before me this day
and being duly sworn acknowledged that then
above fo mwas executed by him.
Witness my hand and notarial seal,this 31 day of /"t9I,C.s-1-- ,20 A 3 i(ict-tix.-c-1 Vvl a--C&' . d-ecui>
Notary —
�1 Seal My expires /�.411 I i ��a5
commission
RACHEL MARTIN HAYES
Notary Public,North Carolina
Gaston County
My Commission Expires
Ma 27,2025
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