NCC233161_FRO Submitted_20231023

,- FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IR E D E L L No person may initiate any land-disturbing activity on one or more acres, YZ acre or more inside a
c: 0 u N v c: 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. r�
1. Project Name DA5 77) "' yogKwoo l)
2. Location of land-disturbing activity: County .1 gq 17lr I--1.- City or Township i?Ci;(�Sy/i L-L i
W
ir r . �Si
Highway/Street .J fl(�-4 .C/?-1) Latitude 3)4'3 4Z.,'t, �,Y Longitude SOSC r72 i ii3j.r
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional,etc.): RE-6 j E J�j TI r L
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): ,
L)V
6. Amount of fee enclosed: $ Z)J d a . 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 V
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name ad-gopl1 -e C_4t 141O/•/ E-mail Address v•r Jvnebiri Cko3ij`n corn
Telephone 104•-2:21_1 01 Cell# "701-1 -7-91" a I Fax# ✓
9. Landowner(s)of Record(attach accompanied page to list additional owners):
T O.P L RT 6 (M) 24/-Y7ii f1/6-232,-00 iiii
Name Telephone Fax Number
3125- M(LLZ: C11) i (6.1414 .-)
Current Mailing Address
Current Street)Address
IS67/917 1 V V m— 4757 ( </-4//1i'=
City State Zip
Zip Q City State Zip
10. Deed Book No. ' J 0 / Page No. J V2-8 613 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):
r
Bi4Ck'� i N r u.ST►r✓1 a�0406 As i�c �i��,lirk.�j�c/ �Mt'�I?/7 € 9 cl, a Coin
Name ' E-mdif Address
61.16 &4ry C ,ynL-)
Current Mailing Address Current Street Address
D24v9f SOW Al 2-3o t l
nt 61 7
City State Zip City State Zip
/y
Telephone /d1j- Z i'19o/ 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:
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:
6640/96 G �AiLA, rafre t,1c cktioii Co t a.; 10 Noy
Name of Registered Agent Ernail Address
Current Mailing Address Current Street Address
ity State Zip City State Zip
Telephone 7oy•-Z6/" Z3o j 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 change3 in the information provided herein.
GiC�'or��b i� 10-1- 1'c,V/ V l,,i lZ
Type o print name Title or Authority
A �� 7- 7/-2 Z5
/2Z5
Signature Date
I, \ 1st oD1r< . IT1 Ac'v ,a Notary Public of the County of (necc.le4-\bLci
State of North Carolina, hereby certify that t>e.c z 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 I I day of ,Jo I," ,20 z3
Nota
Seal /
My commission expires l--uuc, icl, 2-e 2
CHRISTOPHER JOHN CRUMP
NOTARY PUBLIC
Mecklenburg County
North Carolina
My Commission Expires Aug.19,2026
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