NCC233404_FRO Submitted_20231115

.,t- FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IR L D L L L No person may initiate any land-disturbing activity on one or more acres, '/2 acre or more inside a
c ri I i. 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, tr °' '` D
(Please type or print) C
Part A. SEP 2 6 2023
1. Project Name Wevids7 g //S "
2. Location of land-disturbing activity: County lreciell City or Township L�l/4iH.6e/TA srq /!,s/,�4,
Highway/Street girt,/ . Latitude_ lLongitude
3. Approximate date land-disturbing activity will commence: T lS Z0Z3
4. Purpose of development(residential,commercial, industrial, institutional, etc.): A',S1C4d!i74a
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): // /!C_.
CO
6. Amount of fee enclosed: $ Zr/O47. . 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 contactco should erosion and sediment control issues arise during land-disturbing activity:
Name /14✓lA/ /<'//MlC E-mail Address -V/n _/I1XI']C. g/f!/I}lG .Cry",
Telephone / /i Cell# fr.:00 #6.1/33 Fax# 4A✓l'/�
9. Landowner(s)of Record(attach accompanied page to list additional owners):
NKS Or ,'hes 11, cLc (?c{ 9.6-/133 .t/�it-
Teleplfone Fax Number
14 f 50 ,t Lor796//o IA)C.N. --C4ifte
Current Mailing Address Current Street Addres
/yteafai rt'/( ,V 20117 A/olf-
City State Zip City State Zip
10. Deed Book No. Z9BS Page No. 143 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):
,es r PDpezhcs //j a-G 1ltwalklr�k 4vG t!9•Wi ic. .ca.-7
Name E-mail Address
141 $ t1i lon9lec/fet.✓ (its• .ram ,1-Of
Current Mailing Address Current Street Address
ii4 ott- dv//e Al n 1(7 9 ik
City State Zip City �/ State Zip
Telephone 7�) /Jf' "/133 Fax Number 11 4-
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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:
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 py any chansc a in the info atio provided herein.
6C141 Tin I e K1�K � i“fbill -
Type or print na Title or Authority _
Signature Date
!, : 1 e551(ezialia, , a Notary Public of the County of J-re(�Q,1
I
State of North Carolina, hereby ctrtify that �'j(,r}-h n 4{t.1 appeared personally before me this day
and being duly sworn acknowledged that the above forfn was executed by him.
Witness my hand and notarial seal, this ZS day of , 20 7`S
,tt�lt 1111//�� Nota
eivr C FF ll��� 5a�1GA•Tgri,��� Mycommission expires f ) Q� I �(3ZS
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