NCC232642_FRO Submitted_20230901

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
j EROSION & SEDIMENTATION CONTROL
IR E D E L L No person may initiate any land-disturbing activity on one or more acres, 1/2 acre or more inside a
u N T , 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 Waterfront at Langtree Townhomes
2. Location of land-disturbing activity: County Iredell City or Township Mooresville
Highway/Street Langtree Rd. Latitude 35.52917 Longitude -80.867663
3. Approximate date land-disturbing activity will commence: 8/31/2023
4. Purpose of development(residential, commercial, industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 2.62
6. Amount of fee enclosed: $ 458.50 . 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 fiat 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 Joe Venezia E-mail Address [e-mail]
Telephone [phone] Cell# 240.422.6200 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
JRN Development, LLC 240.422.6200
Name Telephone Fax Number
7224 Statesville Road, Suite A 7224 Statesville Road, Suite A
Current Mailing Address Current Street Address
Charlotte NC 28269 Charlotte NC 28269
City State Zip City State Zip
10. Deed Book No. 2887 Page No. 1314 Provide a copy of the most current deed.
Part B.
1. Person(s)or firms)who are financially responsible for the land-disturbing activity(Provide a comprehensive list of all
responsible parties on an attached sheet):
JRN Development, LLC [e-mail]
Name E-mail Address
7224 Statesville Road, Suite A 7224 Statesville Road, Suite A
Current Mailing Address Current Street Address
Charlotte NC 28269 Charlotte NC 28269
City State Zip City State Zip
Telephone [phone] Fax Number
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:
Andrea S. Wood aswoodAwoodlawnc.com
Name E-mail Address
2115 Rexford Road, Suite 310 2115 Rexford Road, Suite 310
Current Mailing Address Current Street Address
Charlotte NC 28211 Charlotte NC 28211
City State Zip City State Zip
Telephone 704.3ti5.104Fi 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Rick Admani President/Owner
Type or print name + Title or Authority
4/18/2023
Signature Date
I, A-1)6 • tik 1-t - , a Notary Public of the County of �`GI 1 _
State of North Carolina, hereby certify that l c ,rA Adl r'ha.Ai, 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 1&1day of April ,20
Notary
Seal 4/ 7/� ,/
My commission expires !_ i 2
April T. Pruitt
NOTARY PUBLIC
Iredell County
North Carolina
,My Commission Expires 4/1 712 62 4
Page 2 of 2